CLINICO-PATHOLOGICAL CASE A 20 year old male was admitted with the chief complaints of episodes of headache, palpitation and

giddiness for three years and blurring of vision for one year. He was asymptomatic till 3 years ago when he started having severe headache in the occipital region accompanied by giddiness and palpitations. He used to get these attacks of and on and was detected to have hypertension. He took antihypertensive drugs (details not known) for about one and half months and stopped them as he improved. One year prior to the present admission he suddenly had blurring of vision and headache. At that time his blood pressure was 210/140 mm Hg. He was treated in a private hospital before being referred to this hospital. He complained of recurrent attacks of palpitations, headache and dryness of mouth and throat. He also gave history of polyuria and increased thirst. He had loss of appetite and had lost 20% of body weight in the past 2 years. There was no history of oliguria, bone pain, dyspnoea or swelling over the body. He had not consumed steroids or any other drugs prior to the onset of this illness. He is not a smoker and does not consume alcohol. He is unmarried. The family history was noncontributory. On examination, his pulse was 108/min and regular. All the peripheral pulses were palpable on both sides and there was no brachio-femoral delay. There was no pallor, cyanosis, icterus, pedal edema or lymphadenopathy or lumps in the body. Jugular venous pressure was normal. His blood pressure records in standing and supine positions were 180/110 mmHg and 250/170 mmHg respectively. Paroxysmal fluctuations in blood pressure were seen during his hospital stay. Examination of the cardiovascular system was normal. The liver was just palpable below the costal margin. The respiratory system was normal. The head and neck was unremarkable. Fundus examination revealed arteriolar narrowing, soft exudates, macular star and papilledema. Investigations revealed a hemoglobin of 10.8G/dl, Total Leukocyte Count 4600/cumm with a differential of N62, E2, L34, M2. Erythrocyte Sedimentation Rate was 8mm at the end of 1 hour [Westergren method]. Fasting blood sugar was 160mg /dl, blood urea was 34 mg/dL, serum electrolytes (Na/K) 137/3.3 mEq/L. Serum calcium and phosphate were 10.5mg/dl and 4.8mg/dl respectively. Routine urinalysis did not reveal any abnormality. Liver function tests, electrocardiogram, and chest X-rays were normal. Based on these findings a provisional diagnosis was made and further tests were ordered to arrive at a diagnosis. Discuss the case systematically and logically to arrive at a Provisional Diagnosis and plan the next set of investigations to arrive at / confirm the diagnosis. These would be provided in the class.