Differential Diagnosis for a 73-year-old Female with Lightheadedness and Dizziness
The patient presents with a complex medical history and symptoms of lightheadedness and dizziness. The differential diagnosis can be categorized as follows:
- Single most likely diagnosis
- Orthostatic hypotension: Given the patient's symptoms worsen when standing or walking and improve when sitting, along with a history of hypertension and recent antihypertensive medication use, orthostatic hypotension is a strong consideration. The patient's high blood pressure reading (190/87) may seem counterintuitive, but it's possible that her blood pressure drops significantly upon standing, leading to symptoms.
- Other Likely diagnoses
- Dehydration: This could be a contributing factor, especially if the patient has been experiencing increased urine output due to her antihypertensive medication or other factors.
- Side effects of medication: The patient's recent disease progression and ongoing treatment for neuroendocrine cancer, as well as her use of Meclizine, could be contributing to her symptoms.
- Hypertensive crisis: Although the patient's symptoms do not entirely align with a typical hypertensive crisis, her elevated blood pressure reading warrants consideration of this diagnosis.
- Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
- Intracranial hemorrhage: Given the patient's history of meningioma and recent disease progression, there is a possibility of intracranial bleeding, which would be a medical emergency.
- Cerebral vasculitis: This is a rare but potentially life-threatening condition that could be related to the patient's neuroendocrine cancer or genetic disorder.
- Brain metastasis: The patient's history of cancer and recent disease progression increases the risk of brain metastasis, which could cause her symptoms.
- Rare diagnoses
- Multiple system atrophy (MSA): This is a rare neurodegenerative disorder that can cause orthostatic hypotension, among other symptoms.
- Pheochromocytoma: Although the patient has neuroendocrine cancer, pheochromocytoma is a rare tumor that could cause episodic hypertension and orthostatic hypotension.
- Autoimmune disorders: Certain autoimmune disorders, such as autoimmune autonomic ganglionopathy, could cause orthostatic hypotension and other symptoms.
Evaluation and Orders
To further evaluate the patient, the following orders could be considered:
- Complete blood count (CBC) to rule out anemia or infection
- Basic metabolic panel (BMP) to assess electrolyte levels and renal function
- Liver function tests (LFTs) to evaluate for potential liver metastasis or other liver disease
- Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) to assess for inflammation
- Urinalysis to evaluate for urinary tract infection or other renal issues
- Brain MRI (if not recently performed) to assess for intracranial hemorrhage, brain metastasis, or other central nervous system abnormalities
- Orthostatic vital signs to confirm orthostatic hypotension
- Medication review to assess for potential side effects or interactions contributing to the patient's symptoms.