7.4.3 Headache attributed to hypothalamic or pituitary hyper- or hyposecretion

Identification: Sex/Age: Male, 38 years History: Hypertension for 2 years, no other relevant history Medication: Antihypertensives (partially controlled) History of Present Illness (HPI): Main symptom: Constant frontal headache for 3 months Characteristics of the pain: Location: Bilateral frontal and retro-orbital Intensity: 6-7/10 Quality: Deep pressure Aggravating factors: Forward head tilt No response to common analgesics Associated symptoms: Intermittent double vision Progressive loss of peripheral vision Increase in the size of feet and hands Erectile dysfunction Physical/Neurological Examination: Physical appearance: Macrognathia, broadening of facial features Visual field test: Bitemporal hemianopsia Neurological: Partial paralysis of the right oculomotor nerve Other: Enlargement of extremities, thickened skin Complementary Exams: Magnetic Resonance Imaging of the Sella Turcica: Pituitary macroadenoma (2.5 cm) with suprasellar extension Laboratory: GH: 15 ng/mL (elevated) IGF-1: 780 ng/mL (elevated) Glucose tolerance test: GH not suppressed Prolactin: 35 ng/mL (slightly elevated)