Differential Diagnosis
The patient's symptoms of left facial tingling, confusion, intermittent headaches, expressive aphasia, double vision, and physical exam findings suggest a complex neurological condition. The history of cocaine use, hypertension, and Marfan syndrome further complicates the diagnosis. Here is a differential diagnosis organized into categories:
- Single most likely diagnosis
- Stroke or Transient Ischemic Attack (TIA): The patient's symptoms of expressive aphasia, double vision, and abnormal extraocular movement of the left eye are highly suggestive of a stroke or TIA, particularly in the context of hypertension and cocaine use, which are risk factors for cerebrovascular disease.
- Other Likely diagnoses
- Cocaine-induced vasculitis or vasospasm: Cocaine use can cause vasculitis or vasospasm, leading to neurological symptoms such as headaches, confusion, and focal neurological deficits.
- Hypertensive encephalopathy: Severe hypertension can cause encephalopathy, characterized by headaches, confusion, and visual disturbances.
- Marfan syndrome-related vascular complications: Marfan syndrome can increase the risk of vascular complications, such as aortic dissection or cerebral aneurysm, which could present with similar symptoms.
- Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
- Subarachnoid hemorrhage: A sudden, severe headache and focal neurological deficits could indicate a subarachnoid hemorrhage, which requires immediate medical attention.
- Cerebral venous sinus thrombosis: This condition can present with headaches, confusion, and focal neurological deficits, and is often associated with a high mortality rate if left untreated.
- Aortic dissection: Marfan syndrome increases the risk of aortic dissection, which can present with severe, tearing chest pain and neurological symptoms if the dissection involves the carotid or vertebral arteries.
- Rare diagnoses
- Migraine with aura: Although less likely, migraines with aura can cause similar symptoms, including visual disturbances, headaches, and focal neurological deficits.
- Multiple sclerosis: This condition can cause a wide range of neurological symptoms, including vision problems, headaches, and focal neurological deficits, although it is less likely given the patient's other medical history.
- Arteriovenous malformation (AVM): An AVM could cause similar symptoms, particularly if it is located in the brain and is bleeding or has caused a seizure.