CASE PRESENTATION

3. 28-year-old lady, not known to have any
medical illness before, presented complaining
of headache and palpitations for 3 months.

4. Headache
• 3 months in duration
• Occipital area
• Dull in nature
• Episodic (5-7 times daily)
• 6-8/10 severity
• Gradually progress in severity
• Not relieved by medication and disturbs her sleep
• Usually at rest and triggered by activity or stress
• No aura: blurred vision, nausea, vomiting, sensory disturbance
• No neurological weakness, photophobia, fever, neck stiffness, sinusitis or
visual disturbance

5. Palpitations:
• 3 months in duration
• Sudden onset and offset
• Fast regular beats
• Lasts for one minute or less.
• Usually at rest and triggered by activity or stress
• Disturbs her sleep
• Associated with sweating
• Combined with or without headache
• + SOB & vomiting every morning (not projectile, little in amount, only water
or food contents)

6. • Last month patient went to a local hospital and
sought medical advice and found to have DM (RBS
14) and persistent high blood pressure (180/130) and
started on AntiHTN medications and oral
hypoglycemic agent.

7. Associated symptoms
• Dizziness
• Generalized fatigue
• Anorexia
• Weight loss in the last 2 months (10 kg)
• Nervousness and irritability
• Hotness
• Hair loss
• Heat intolerance

8. • No history of similar illness before
• No history of chronic illness in the past
• No history of previous admissions
• No history of blood transfusion

9. • Surgical removal of scalp lipoma at age of 8
• C/S 5 years ago with a healthy child complicated with
post surgical wound infection

10. Obstetrics:
• G1P1+0
• 5 years ago.
• Regular follow up.
• Non complicated pregnancy (No GDM, pre-eclampsia).
• Delivery: C/S 2ry to obstructed labor.
• Healthy female neonate (child).

11. Menstruation
• Age of menarche at age of 14 years old
• Regular
• Every 30 days
• Average bleeding
• 5 days in duration
o Patient started to have irregular menstrual cycle after the last pregnancy.
o She sought medical advice 2 years back and started on OCP (??) to
regulate her menstruation. and she used it for 3 months with no benefit.
o Then she sought another medical advice and started on another OCP (??) ,
also she used it for 3 months with no benefit
o Then her menstrual cycle became normal 6 months back (with no meds)
but becomes more in duration (8 days) with average bleeding

12. • CVS: no chest pain, orthpnea, PND, syncope or intermittent
claudication.
• Resp: no cough, sputum, wheezing or snoring
• GI: no dysphagia, heartburn, diarrhea, constipation or PR
bleeding.
• GU: no dysuria, change in color of urine, change in frequency,
dysuria, urgency, incontinence, retention or nocturia.
• MS: no joint pain, limitation or skin rash.
• CNS: no numbness, weakness (proximal or distal) or LOC
• Hem: no itching, yellowish discoloration of eyes or skin,
petechia, easy bruises, epistaxes or prolonged bleeding

13. • Paracetamol 500mg – 1g PRN
• Metformin 1g BID
• Hydrochlorothiazide 25mg OD
• Carvedilol 6.25mg BID
• Lisinopril 5mg OD
• Amlodipine 5mg OD
• OCP ??
 Patient was started on one AntiHTN (??) medication, then her
symptomes becomes more severe, including headache, palpitations
and sweating..
# Allergy not known

14. • No family history of similar illness.
• No history of malignancy or blood disorder
among the family
• Mother GDM  DM – HTN
• 7 healthy sisters and father

15. • From Algatif
• Married for 6 years with a single healthy child
• Housewife.
• Non smoker (passive smoker).
• No use of illicit drugs, alcohol or herbs
• High school education level
• Good socioeconomic status
• No history of recent travel.

16. • 28-year-old lady, not known to have any
medical illness before, presented with
paroxysmal headache and palpitations for 3
months.
• Associated with sweating, dizziness,
generalized fatigue, nervousness and
irritability.

18. • BP 155/98
• HR 117 (regular fast pulses, with no radio-radial or radio-
femoral delay)
• RR 20 BP
BP
• Temp 37.1oC Sitting 174/118
Sitting 174/118
Standing 148/100
Standing 148/100
• SpO2 97% RA
• Height 156 cm
• Weight 91.6 kg
• BMI = 37.6

19. General
• Patient conscious, alert and oriented to PPT
• Obese
• Not pale, jaundiced or cyanosed
• Sitting comfortably on bed, not distressed
• Sweating

20. Hands
• Fine kinetic tremor.
• Warm sweaty hands.
• No clubbing, onycholysis, peripheral cyanosis, joint deformity,
palmer erythema or muscle wasting
• No skin pigmentation
Face
• No pallor or jaundice
• No protrusion of the eye, no led lag or retraction
• No obvious hair loss
• Good oral hygiene
• No dorsocervical or supraclavicular fat fullness

21. Neck
• Normal thyroid and Lymph nodes exam
• No retrosternal dullness on percussion.
Legs
• No lower limbs edema
• Palpable peripheral pulses (Dorsalis Pedis , PTA)

22. CVS
Inspection:
• No scar, deformity or visible pulsation.
• JVP ??
Palpation:
• Normal localize apex beat at 5th ICS mid-clavicular line, no
heaves or thrills
Auscultation:
• S1 + S2 + 0
• Carotids with no bruits

23. Chest
Inspection:
• Normal shape of the chest
• No chest deformity, scar, prominent veins or use of accessory muscles
Palpation:
• Central trachea
• Normal chest expansion
• Normal vocal fremitus
Percussion:
• Resonance all over the chest
Auscultation:
• Normal intensity vesicular breathing bilaterally with no added sounds

24. Abdomen
Inspection:
• Striae (pale), abdominal distension
• No scars, visible pulsations or veins, no pigmentation
Palpation:
• Not tender to palpation, no organomegally or palpable masses
Percussion:
Normal liver span
No ascitis
Auscultation:
• +ve bowel sounds
• No bruits, friction rubs or venous hums

25. CNS
• Patient conscious, alert and oriented to PPT
• Higher mental functions normal
• Pupils reactive bilaterally
• CN unremarkable
• Normal tone
• Normal reflexes
• Power 5/5 all limbs
• Sensation intact
• Normal vibration and position sense
• Normal Gait and coordination

26. Fundoscopic exam
• Difficult to assess
(Referred to Ophthalmology)

27. Urine dipstick

28. • 28-year-old lady, not known to have any medical illness
before, presented with paroxysmal headache and
palpitations for 3 months.
• Associated with sweating, dizziness, generalized fatigue,
nervousness and irritability.
O/E
• Vitals : BP 155/98 , HR 117
• BMI 37.6
• Fine kinetic tremor, warm sweaty hands
• Unremarkable CVS, chest, abdominal and CNS examination

37. • patient admitted as a case of 2ry HTN for further investigation
• Monitor vital signs regularly
• TFT
• Plasma Metanephrine level
• Renin level, Aldosterone-Renin Ratio
• Vitamin D, PTH
• 24 hours urine collection for Catecholamines and cortisol levels
• U/S renal artries
• CT Abdomen
• CT brain
• Endorinology consultation

39. Conclusion:
• Evidence of previous right frontal craniotomy noted.
• No acute territorial infarction or hemorrhage could be
seen.
• No evidence of focal lesion, mass effects or midline shift
could be seen.