A 37 years old lady
Address:  Muar, Johor.
Occupation:  Housewife
Date of admission:  23/08/2006
Date of examination:  23/08/2006
Date of discharged:  25/08/2006

Chief complaint:
· High blood pressure (140/90  mmHg), headache and diplopia since her last
childbirth in May 2005.
· Increased weight of 20 kilograms within 5 months.

History of present illness:
Patient was on routine check-up every 2 months on her blood pressure
following delivery in May 2005 (patient has pregnancy-induced hypertension,
blood pressure before delivery was  140/100  mmHg).  Patient’s blood
pressure had not relieved after that.

Patient has headache and pain in the neck, around the head every morning
since her last childbirth.  The headache was severe, intermittent, throbbing
in nature and progressively worse, which caused her to feel nauseated and
vomit.   Resting and the nausea relieve it and vomiting is not related to
food.

Patient complaint of lethargy after few minutes of accustomed work like
doing housework.  She felt weakness especially in the proximal lower limbs.

Patient also had palpitations that occurred after delivery.  There is no
history of missing beats.  There is no history of loss of consciousness.

Diplopia started together at the same time after the delivery with blurring
of vision, seeing ‘black dots’ and photophobia.

There is no history of gastric pain, no history of joint pains.

Patient also complains of chest pains once a while especially before sleep.
The pain is diffuse, moderate, burning in nature, which lasted for about 30
minutes and relieved by resting.  The pain does not radiate.  It is
associated with numbness of the right hand and fingers.

There is progressive increased of weight of 20 kilograms within the 5 months
(now is 70 kilograms)




Drug History:
Patient was on Depo Provera 1 month after her last delivery (given every 2
months).
Tablet Atenolol 100 mg b.d.
Tablet Ranitidine 150 mg b.d.
There is no history of traditional medicine usage.

Allergy History:
Patient is allergic to one type of antibiotic (unable to name the drug).
Patient has itchiness after taking the drug.

Menstrual History:
Patient attained menarche at the age of 14 years.
The cycle was irregular (2/56 days), clots, dysmenorrhoea (congestive in
nature), previously 4-5/28 days cycle, regular

Past History:
There is no history of hypertension, diabetes mellitus, tuberculosis,
ischaemic heart disease.
There is no history of any operation.

Pregnancy history:
· 1992, delivered in the private hospital in Seremban, term pregnancy, no
complications, spontaneous vertex delivery (SVD), livebirth, baby girl, 2.6
kg, alive and well.
· 1993, baby girl passed away after 7 days of delivery due to septicaemia.
· 1995, delivered in Seremban Hospital, term pregnancy, no
complications,spontaneous vertex delivery (SVD), livebirth, baby girl, 2.4
kg, alive and well.
· 1998, delivered in Seremban Hospital, 7 months of pregnancy, mother had
pre-eclampsia (blood pressure back to normal after 1 month), SVD, livebirth,
baby girl, 1.5 kg, baby in Neonatal intensive care unit (NICU) due to
prematurity, now alive and well.
· 2002, delivered in Muar Hospital, 8 months of pregnancy, mother had
pre-eclampsia (blood pressure back to normal after 1 month), SVD, livebirth,
baby girl, 2 kg,
alive and well.
· 2004, delivered in Muar Hospital, 8 months of pregnancy, mother had
pre-eclampsia (blood pressure back to normal after 1 month), SVD, livebirth,
baby girl, 2 kg,
alive and well.
· 2005, delivered in Muar Hospital, 7 months of pregnancy, mother had
pre-eclampsia (blood pressure remains high until now), SVD, passed away
after 1 hour of birth due to torn umbilical cord, patient was given blood
transfusion of 12 units.


Family History:
Father, 66 years old, has ischaemic heart disease and diabetes mellitus (on
insulin injection).
Mother, 56 years old, asthmatic, on inhaler.
Patient has 5 siblings.
She is the second in the family.
Her sister , 32 years old, has gallstones, 2006, operated on.
Her brother, 21 yeas old, is asthmatic, on salbutamol pill.


Social History:
Patient does not smoke nor consume alcohol.
Average income is RM1,500.
Patient is coping well at home.
Patient stays in a double-storey house.
Patient has difficulty in climbing stairs (after 10 steps, she is
dyspnoeic), so she lives downstairs.
Patient lives 10 minutes drive from her house.
Micturition is 6-8 times/day (2 nocturia).
Bowel habits are normal, once/day.


Provisional diagnosis:  Young hypertensive with Cushingoid syndrome
probably due to pituitary adenoma or adrenal hyperplasia.




General examination

Patient is sitting comfortably, alert, conscious and cooperative.
There is buffalo hump.
There is no pallor, no icterus, no cyanosis, no clubbing, no generalized
lymphadenopathy.
Oral hygiene is moderate, the teeth and gums are healthy, the tongue is not
coated, the throat is not inflamed.

Vital signs:
Pulse rate: 76 beats per minute, regular, normal volume, no special
character, no blood vessel thickening.
Blood pressure:  132/80 mmHg
Temperature:  37.2OC
Respiratory rate: 20 breaths per minute

Jugular venous pulse:  Not raised.

Central Nervous System examination

Glasgow Coma score:  15

Higher Mental function:  Intact

Cranial Nerves:
Olfactory nerve:  Intact
Optic nerve:
                   Visual acuity:  Diplopia in both eyes.
                                            Right eye- Diplopia on superior
and lateral gaze
                                            Left eye – Diplopia on lateral
gaze
                   Visual field: Peripheral visual field decreased
especially in the right eye on lateral gaze.
                   Pupillary light reflex:  Normal
                   Colour vision:  Not tested
                   Accommodation reflex:  Normal
Occulomotor , trochlear, abducent nerve:  Intact
Trigeminal nerve: Intact
Facial nerve: Intact
Vestibulo-cochlear Nerve:  Intact
Glossopharyngeal and vagus nerve:  Intact
Spinal accessory nerve:  Intact
Hypoglossal nerve:  Intact


Motor system:
Attitude of limb -  Upper limb – arm and forearm are flexed
                             Lower limb – flexed
There is no muscle wasting.
The tone of the upper and lower limbs is normal.
The power of both upper limbs and lower limbs are 5/5.
Coordination:  Normal
There are no involuntary movements.
The gait is normal.
Reflexes are normal.

Sensory System:  Intact

There are no cerebellar signs or meningeal signs.

Cardiovascular system:

Mitral Area:  S1 S2 are heard
                S1 normal
                S2 normal
                There are no murmurs.

Tricuspid area:  S1 S2 are heard
                     S1 normal
                     S2 normal
                     There are no murmurs

Pulmonary area:  S1 S2 are heard.
                       S1 normal
                       S2 normal.
                       There are no murmurs.

Aortic area:  S1  S2 are heard.
                 S1 normal.
                 S2 normal
                 There are no murmurs.




Abdomen examination:

Abdomen is soft and non-tender.
There is central obesity.
There is a Pfannenstiel’s incision scar at the suprapubic area measuring 8
cm.
There is no hepatomegaly, no splenomegaly, no ascites.
Kidneys are not ballotable.
Bowel sounds are heard – 5 per minute.



Respiratory system examination:

Air entry equal on both sides.
Normal vesicular breath sounds.
There are no crepitations.




Investigations done

23/08/2006
Full blood count:
White blood cells:  8.10 x 10-3 /uL  (Normal range: 4-11x 10-3/uL)
Neutrophils:  52.1%
Lymphocytes: 39.8 %
Monocytes:  4.9%
Eosinophils:  2.8%
Basophils:  0.4%
Red blood cells: 4.34 x 10-6/uL  (3.8-5.8 x 10-6/uL)
Hemoglobin: 11.3 g/dl (11.5-16.5 g/dl)
Hematocrit: 33.8% (36-48 %)
Mean corpuscular volume : 77.9 fL (80-95 fL)
Mean corpuscular hemoglobin: 26.0 pg (27-34 pg)
Mean corpuscular hemoglobin concentration:  33.4 %
Platelet:  276 x 10-3/uL  (150-400 x 10-3/uL)

Liver function test:
Total protein:  86g/L (65-85 g/L)
Albumin:  41 g/L (35-50 g/L)
Globulin:  45 g/L  (20-35 g/L)
A/G  ratio:  0.9 (1-2.2)
Total bilirubin:  8 mmol/L  (up to 22.2 in adult)
Alkaline phosphatase:  63 U/L  (42-98 U/L)
Alanine aminotransferase:  25 U/L  (up to 32 U/L)


Coagulation profile
Prothrombin time:  12.4 seconds (12-72 seconds)
International normalized ratio: 1.08
Activated partial thromboplastin time:  22.3 seconds


Random blood glucose:  5.4 mmol/L  (3.8-10.0 mmol/L)

Renal profile:
Serum creatinine:  59 mmol/L  (40-115 mmol/L)
Uric acid:  294 mmol/L  (140-420 mmol/L)
Urea:  4.1 mmol/L  (2.5-8.3 mmol/L)
Sodium:  136 mmol/L  (135-145 mmol/L)
Potassium:  3.9 mmol/L  (3.5-5.0 mmol/L)
Chloride:  102 mmol/L  (98-108 mmol/L)




Urine Full examination and microscopic examination (24/08/2006)
Blood:  Negative
Bilirubin:  Negative
Urobilinogen:  Normal
Ketone;  Negative
Protein:  Negative
Nitrate:  Negative
Glucose:  Negative
pH:  5.5
Specific gravity:  1.020
Leucocytes:  Trace


Immunoassay:
24-hour urine cortisol:  1385 nmol/24 hours (116-600 nmol/24 hours)
Urine cortisol volume:  680 ml.


Adrenocorticotropic hormone (ACTH) and growth hormone levels – (Awaiting
results)


X-ray:  Left lateral view of the skull to look at the pituitary fossa
(awaiting results)


Treatment:
Prazocin 1mg t.d.s.

23/08/2006:  Enalapril  5 mg  b.d.


Diagnosis:  Young hypertensive with Cushingoid syndrome due to ?pituitary
adenoma.



Discussion:
·  There is increased cortisol in the 24-hour urine. Dexamethasone
suppression test can be done to measure the response of the adrenal glands
to adrenocorticotropic hormones (ACTH).  The Dexamethasone pills are given
by mouth, then blood and urine are collected for cortisol and other adrenal
hormones. A screening test is done initially with an overnight test, if it
is abnormal, a  4-day test divided into low and high dose Dexamethasone is
needed. To separate ACTH dependent (pituitary or ectopic) from independent
types (adrenal tumour), a blood test for ACTH in the morning is done.
·  CT scan or MRI can be used to find the tumour.
·  Petrosal sinus sampling might be needed.
Treatment:

· Transsphenoidal resection of the pituitary tumour
· Replacement hormones for cortisol, thyroid and gonadal (sex) hormones when
the patient has ACTH deficiency and other pituitary hormones after the
surgery
· Fertility can be restored with special hormonal therapies.
· Radiotherapy if the tumour cannot be removed.
·  Metyrapone, amino-glutethimide or ketoconazole can be used
·  Surgically removal of the adrenal adenomas