A 28-year-old lady presented with headaches and palpitations for 3 months. On examination, she had a blood pressure of 155/98, heart rate of 117, BMI of 37.6, and fine kinetic tremors with sweaty hands. No significant abnormalities were found on cardiovascular, chest, abdominal, or neurological examinations. She was admitted for further investigation of secondary hypertension. Tests were ordered to evaluate endocrine and renal causes of her high blood pressure. A CT of the brain found evidence of a prior craniotomy but no acute issues.

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.