CASE 64: HEADACHES
History
A 32-year-old woman is admitted to hospital with a 3-day history of failing vision, a reduced
urinary output and ankle swelling. Four months earlier she had developed headaches which
were generalized, throbbing and not relieved by simple analgesics. She does not smoke or
drink alcohol; she is married with three children aged 8, 6 and 2 years. Her husband works
for a travel firm which requires him to be absent frequently from home.
Two months before admission she consulted her general practitioner (GP) for the headaches;
tension headaches were diagnosed and codeine phosphate prescribed. This gave no relief,
and 3 weeks later she saw her GP again, and the analgesia was changed to a codeine-
containing compound analgesic.
Her symptoms continued unchanged until 3 days before admission when the headaches
became worse, her vision became blurred and during the 24 h before admission she noted
oliguria and ankle swelling. She presented at the emergency department.
The only other relevant medical history is the development of hypertension during the last
trimester of her third pregnancy which was treated with rest and an antihypertensive.
Delivery was spontaneous at term, and the antihypertensive drug was discontinued post-
partum. The patient had not attended any postnatal clinics and her blood pressure had not
been measured at the consultations for her headache.
Examination
She is conscious and seems well, but pale and clinically anaemic. There is slight ankle
oedema. The blood pressure is 190/140 mmHg, and the jugular venous pressure is not raised.
Otherwise her chest, heart and abdomen are normal. In the CNS, examination of the fundi
shows papilloedema, retinal haemorrhages and exudates in both eyes. Visual acuity is
reduced.
NormalHaemoglobin 10.8 g/dL 11.7–15.7 g/dL
Mean corpuscular volume (MCV) 84 fL 80–99 fL
White cell count 8.1% 109 /L 3.5–11.0% 109 /L
Platelets 200 % 109 /L 150–440% 109 /L
Sodium 136 mmol/L 135–145 mmol/L
Potassium 5.1 mmol/L 3.5–5.0 mmol/L
Bicarbonate 22 mmol/L 24–30 mmol/L
Urea 22.9 mmol/L 2.5–6.7 mmol/L
Creatinine 698 &mol/L 70–120&mol/LUrine:'''protein;'bloodINVESTIGATIONS
Questions
- What is the diagnosis?
- What is the immediate management?