Differential Diagnosis
- Single most likely diagnosis
- F) Subclavian steal syndrome: This condition is characterized by a discrepancy in blood pressure between the two arms, which is present in this patient (140/90 mm Hg in the right arm and 110/70 mm Hg in the left arm). The symptoms of dizziness, light-headedness, and blurred vision, especially when engaging in activities that involve raising the arms (such as cutting hedges with hand clippers), are consistent with subclavian steal syndrome. This occurs due to the compression or stenosis of the subclavian artery, leading to a reversal of blood flow in the vertebral artery, which can cause cerebral hypoperfusion.
- Other Likely diagnoses
- B) Cardioneurogenic (vasovagal) syncope: This is a common cause of syncope, especially in younger individuals, but can occur at any age. The triggers for vasovagal syncope can be diverse, including pain, stress, or certain positions. While the patient's age and occupation might not be as typical for vasovagal syncope, the episodic nature of the symptoms could still fit this diagnosis.
- C) Meniere disease: Although primarily associated with vertigo, hearing loss, and tinnitus, Meniere disease could potentially cause episodes of dizziness and imbalance. However, the lack of auditory symptoms and the specific triggers (cutting hedges) make this less likely.
- Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
- D) Myocardial ischemia: Although the ECG shows no abnormalities, myocardial ischemia can cause dizziness and should always be considered, especially in a 62-year-old patient. The fact that symptoms occur with physical exertion (cutting hedges) could suggest an ischemic cause.
- A) Atrial fibrillation: This arrhythmia can lead to reduced cardiac output and symptoms of dizziness or syncope. Although the pulse is regular at the time of examination, atrial fibrillation can be paroxysmal, and thus, it's a diagnosis that should not be missed.
- Rare diagnoses
- E) Seizure disorder: While seizures can cause a variety of symptoms, including dizziness and loss of balance, the description provided does not strongly suggest a seizure disorder, especially given the lack of other seizure-like activity and the specific triggers for the episodes.
- Other rare vascular or neurological conditions could also be considered but are less likely given the information provided.