Differential Diagnosis for Vertigo in an Elderly Man

Single Most Likely Diagnosis

• Benign Paroxysmal Positional Vertigo (BPPV): This condition is common in the elderly and can be exacerbated by factors such as diabetes and hypertension, although the exact link is not fully understood. The symptoms of vertigo, especially triggered by positional changes, align with BPPV.

Other Likely Diagnoses

• Vestibular Migraine: Given the patient's history of hypertension, which can be a migraine trigger, and the fact that migraines can cause vertigo, this diagnosis is plausible. However, the absence of headache does not rule out vestibular migraine.
• Meniere's Disease: Although less common, Meniere's disease could be a consideration, especially if the patient experiences hearing loss or tinnitus alongside vertigo. The disease's unpredictable nature and potential for episodic vertigo make it a possible diagnosis.
• Diabetic Neuropathy: The patient's history of insulin-dependent diabetes mellitus type 2 could lead to peripheral neuropathy, which might affect balance and cause vertigo. However, this would typically be accompanied by other symptoms of neuropathy.

Do Not Miss Diagnoses

• Posterior Circulation Stroke or Transient Ischemic Attack (TIA): Although the patient has orthostatic vitals that are negative, a stroke or TIA in the posterior circulation (vertebrobasilar system) can cause vertigo and must be considered due to the high risk of severe consequences if missed. The patient's history of uncontrolled hypertension increases the risk of cerebrovascular events.
• Cardiac Causes (e.g., Arrhythmias): Certain cardiac conditions, such as arrhythmias, can lead to reduced cerebral blood flow, causing vertigo. Given the patient's age and history of hypertension, cardiac causes must be ruled out.

Rare Diagnoses

• Acoustic Neuroma: A benign tumor on the vestibulocochlear nerve, which could cause vertigo, hearing loss, and tinnitus. This is less likely but should be considered if other symptoms are present or if the vertigo is persistent and unexplained by other causes.
• Multiple System Atrophy (MSA): A rare neurodegenerative disorder that can cause vertigo among other symptoms like autonomic dysfunction, parkinsonism, and cerebellar ataxia. The diagnosis of MSA would be considered if the patient has a combination of these symptoms and other causes have been ruled out.