28/09/2026
CASE REPORT
*Hypertensive Heart Disease with Neurologic and Somatic Symptoms in a 70-Year-Old Female: A Diagnostic Pitfall and Multi-Disciplinary Approach*
*Authors:* Okojie E.E., Folorunso T.
*Affiliation:* Federal Medical Centre, Owo, Ondo State, Nigeria
*Date:* August 2026
ABSTRACT
We report a case of a 70-year-old known hypertensive female who presented with a 5-month history of severe vertex headache, poor sleep, easy fatigability, orthopnea, and exertional dyspnea associated with abnormal bodily sensations described as "peppery, worm-like crawling" on the head. Initial assessment in the Emergency Unit suggested moderate depressive disorder with somatic features and amitriptyline was commenced. Subsequent review by the Psychiatry team using the ORGANIC-13 screening tool scored 14/26, indicating moderate probability of organic illness, and a primary psychiatric diagnosis was rejected. Cardiology and Neurology teams were co-involved. Cardiology suspected hypertensive heart disease with early heart failure features, while Neurology considered intracranial pathology. Her blood pressure improved from 160/100 mmHg on admission to 140/90 mmHg on triple antihypertensive therapy. Investigations revealed mild leukocytosis and elevated ESR with borderline dyslipidemia; ECG, echocardiography, brain MRI and EEG are pending. This case highlights the importance of ruling out organic causes before attributing somatic symptoms to psychiatric illness in elderly hypertensives and demonstrates the value of multi-disciplinary collaboration.
*Keywords:* Hypertension, Hypertensive Heart Disease, Heart Failure, Somatic Symptoms, ORGANIC-13, Geriatric Medicine, Multi-disciplinary Care.
INTRODUCTION
Somatic symptoms such as fatigue, poor sleep, and headache in elderly hypertensive patients often pose a diagnostic challenge. The overlap between cardiac, neurologic, and psychiatric presentations necessitates a multi-disciplinary approach to avoid misdiagnosis, especially in resource-limited settings where elderly patients frequently present late with multiple comorbidities.
CASE PRESENTATION
*History of Presenting Complaint*
A 70-year-old female presented with a 5-month history of severe, central, throbbing headache localized to the vertex, accompanied by generalized body pain and weakness. She reported poor sleep with a sensation of "internal heat", an odd "crawling/peppery/worm-like" sensation on the head, easy fatigability, and dyspnea on moderate exertion. She developed orthopnea, requiring multiple pillows and open windows at night, and adopted a self-imposed cardiac position for relief. Associated symptoms included excessive sweating and palpitations. There was a history of non-productive cough that resolved with unspecified medication. She also reported reduced appetite and weight loss over 3 months. She denied fever, chest pain, vomiting, diarrhea, or urinary symptoms.
*Past Medical History*
Known systemic hypertension diagnosed 2 years prior, on treatment. Known peptic ulcer disease. No known diabetes mellitus. No known drug allergy. No history of smoking or alcohol use.
*Physical Examination*
On examination, she was conscious, alert, and oriented in time, place and person. She was not in respiratory distress, anicteric, not pale, no pedal edema, no peripheral lymphadenopathy.
Vitals: Blood pressure improved from 160/100 mmHg on admission to 140/90 mmHg on current therapy. Heart rate 98 bpm on admission, improved to 72 bpm. Respiratory rate and temperature were within normal limits.
Cardiovascular System: Apex beat not displaced. S1 S2 heard, no murmurs. No elevated JVP.
Respiratory System: Chest clinically clear, no crackles.
Central Nervous System: Higher mental functions intact. No meningeal signs, no focal neurological deficits. Cranial nerves intact. Perception was abnormal - persistent "peppery/worm-like" sensation on the scalp without objective skin changes.
INVESTIGATIONS
_Completed:_
1. Full Blood Count: WBC 10.4 x 10^9/L (Neutrophils 59%, Lymphocytes 29%), HCT 41% - within normal limits.
2. Erythrocyte Sedimentation Rate (ESR): 52 mm/hr - mildly elevated (Normal 0-20 mm/hr).
3. Blood Glucose: RBS 6.0 mmol/L, FBS 4.3 mmol/L - normal.
4. Lipid Profile: Total Cholesterol 6.2 mmol/L, Triglyceride 0.7 mmol/L, HDL 0.9 mmol/L, LDL 3.4 mmol/L - borderline dyslipidemia.
_Pending/Requested:_
12-lead ECG, Echocardiography, Chest X-ray, Brain MRI, Electroencephalogram (EEG).
MULTI-DISCIPLINARY ASSESSMENT
1. *Emergency Unit:* Initial impression was Moderate Depressive Disorder with somatic features and anxiety in a known hypertensive. Commenced on Amlodipine 10mg nocte and Amitriptyline 25mg nocte.
2. *Psychiatry Team:* Re-evaluated the patient. Primary psychiatric diagnosis was rejected. ORGANIC-13 score was 14/26 suggesting moderate likelihood of organic illness. Amitriptyline was discontinued.
3. *Neurology Team:* Assessment of 1-month to 5-month throbbing vertex headache with abnormal scalp sensation. CNS examination intact. Impression: Rule out Intracranial Hemorrhage (ICH) / Space Occupying Lesion (SOL). Plan: Brain MRI and EEG.
4. *Cardiology Team:* Primary diagnosis: Systemic Hypertension with suspected Hypertensive Heart Disease / Heart Failure (orthopnea, exertional dyspnea, fatigue, palpitations). Plan: Optimize antihypertensives, cardiac evaluation with ECG, Echocardiogram and CXR.
MANAGEMENT
Initial therapy: Amlodipine and Amitriptyline.
_Revised Discharge Medications:_
1. Telmisartan 80mg daily
2. Metoprolol 50mg daily
3. Amlodipine 5mg daily
4. Atorvastatin daily
5. Clopidogrel 75mg daily / 200mg BD for 1 week (for cardiovascular prophylaxis)
Blood pressure and heart rate showed good initial response to triple antihypertensive therapy and statin.
DISCUSSION
This case illustrates a common diagnostic pitfall in geriatric medicine: attributing new somatic symptoms to psychiatric illness. The initial emergency assessment favored depressive disorder, a common bias when elderly patients present with vague complaints of poor sleep, fatigue, and headache.
However, formal psychiatric screening using ORGANIC-13 (score 14/26) correctly redirected the diagnostic pathway towards organic pathology. The constellation of orthopnea, exertional dyspnea, excessive sweating, palpitations and easy fatigability in a known hypertensive is highly suggestive of hypertensive heart disease progressing to heart failure, even in the absence of pedal edema or chest crackles. Simultaneously, the atypical, persistent vertex headache with abnormal tactile perception ("crawling/peppery") warranted neurologic evaluation to exclude intracranial hemorrhage or space-occupying lesion, especially with mildly elevated ESR.
Borderline dyslipidemia and elevated ESR are additional cardiovascular risk factors. The improvement in BP and pulse rate with triple therapy suggests good initial response, but definitive cardiac and neurologic diagnoses await pending investigations.
CONCLUSION
In elderly hypertensive patients presenting with non-specific somatic symptoms, a high index of suspicion for organic pathology is required. Multi-disciplinary collaboration between Emergency Medicine, Psychiatry, Neurology, and Cardiology was key in redirecting management from a purely psychotropic approach to a comprehensive somatic workup. This case underscores that psychiatry remains crucial in geriatric care not only for treatment but for excluding organic disease.
FOLLOW-UP PLAN
1. Cardiology clinic follow-up with results of Echo, ECG, and CXR.
2. Neurology clinic in 2 weeks with Brain MRI and EEG results.
3. Continue current antihypertensive and statin therapy with strict adherence.
4. Patient and family education on medication adherence, low-salt diet, and red-flag/warning signs requiring emergency presentation.
