Comprehensive Workup for a 33-Year-Old Female with Paresthesia, Cephalalgia, and Hypertension
The patient requires urgent neuroimaging with MRI brain with and without contrast, MRV head, and comprehensive blood work to evaluate for cerebral venous thrombosis, intracranial hypertension, or other neurological causes of her symptoms.
Initial Evaluation
Neurological Workup
- Brain MRI with and without contrast to evaluate for structural abnormalities, signs of increased intracranial pressure, and to exclude secondary causes of headache 1
- MRV (Magnetic Resonance Venography) of the head to rule out cerebral venous thrombosis, especially given the whole-body paresthesia and persistent headache 1
- Consider lumbar puncture with opening pressure measurement if neuroimaging suggests increased intracranial pressure 2
Cardiovascular Evaluation
- 24-hour ambulatory blood pressure monitoring to characterize the pattern and severity of hypertension 1
- 12-lead ECG to assess for cardiac abnormalities and evaluate for potential cardiac cephalgia 1, 3
- Echocardiogram to evaluate for structural heart disease that could contribute to hypertension 1
Laboratory Testing
- Complete metabolic panel including electrolytes, renal function (creatinine, eGFR), and liver function tests 1
- Complete blood count to evaluate for anemia or other hematologic abnormalities 1
- Thyroid function tests (TSH, free T4) given the patient's fatigue, weight gain, and constipation 1
- Urinalysis with urine albumin/creatinine ratio to assess for renal involvement 1
- Lipid profile and fasting glucose to evaluate for metabolic risk factors 1
Rationale for Urgent Neuroimaging
The patient's presentation raises significant concerns for several serious neurological conditions:
Cerebral Venous Thrombosis (CVT): The combination of whole-body paresthesia, persistent headache, and elevated blood pressure is concerning for CVT, which requires prompt diagnosis and treatment 1
Idiopathic Intracranial Hypertension (IIH): Given the patient's demographic (young female), recent weight gain, and headache, IIH should be considered, especially since the emergency department workup was reportedly normal 2, 4
Secondary Causes of Intracranial Hypertension: The patient's medication regimen (oral contraceptives plus IUD) could potentially contribute to a hypercoagulable state or secondary intracranial hypertension 5
Specific Concerns and Management Considerations
Hypertension Evaluation
- The patient's blood pressure readings are concerning (187/105 mmHg), requiring urgent evaluation 1
- Secondary causes of hypertension should be investigated given the acute onset and significant elevation 1
- Evaluate medication interactions, particularly the combination of oral contraceptives and IUD 1
Neurological Symptoms
- The whole-body paresthesia with oral involvement suggests a central neurological process rather than a peripheral one 1
- The differential diagnosis for these symptoms includes:
Endocrine Evaluation
- The constellation of constipation, insomnia, fatigue, and weight gain suggests possible thyroid dysfunction 1
- Consider additional endocrine workup if initial thyroid testing is abnormal
Follow-up Plan
- Arrange for neurological consultation after neuroimaging results are available 1
- Consider ophthalmology evaluation with fundoscopy to assess for papilledema, especially if headaches persist 1, 4
- Implement blood pressure monitoring and management based on initial findings 1
- Re-evaluate the patient's medication regimen, particularly the combination of oral contraceptives and IUD 1
Warning Signs Requiring Immediate Attention
- Worsening headache, especially with Valsalva maneuvers 4
- Visual changes, including transient visual obscurations 4
- Blood pressure >180/110 mmHg (hypertensive emergency) 1
- New focal neurological deficits 1
The patient's presentation with paresthesia, cephalalgia, and significantly elevated blood pressure requires thorough investigation to identify potentially serious underlying conditions and implement appropriate treatment.