From the Guidelines
For an 82-year-old female presenting with lightheadedness, normal EKG, and no chest pain or shortness of breath, the appropriate workup should include orthostatic vital signs, complete blood count, comprehensive metabolic panel, and blood glucose measurement. Additional testing should include cardiac biomarkers (troponin), thyroid function tests, and a urinalysis to rule out infection 1. A medication review is essential to identify potential causes of lightheadedness, particularly antihypertensives, diuretics, or sedatives that may cause hypotension or central nervous system effects. Some key points to consider in the workup include:
- A thorough neurological examination should be performed to assess for focal deficits, and depending on findings, further neuroimaging such as CT or MRI of the brain may be warranted.
- In elderly patients, lightheadedness often has multifactorial causes including dehydration, medication side effects, anemia, or electrolyte abnormalities.
- If cardiac concerns persist despite normal initial EKG, consider Holter monitoring or event recording to capture intermittent arrhythmias, as recommended by guidelines for the management of transient loss of consciousness 1.
- Assessment of fall risk and home safety is also important given the patient's age and presenting symptom, which could predispose her to falls and subsequent injury. It's also important to note that, according to the ACR Appropriateness Criteria, head CT and/or head MRI is not recommended for patients with syncope or presyncope without other conditions that may require imaging, such as trauma or neurologic deficits 1. Given the patient's age and presentation, a careful and targeted approach to the workup is necessary to identify the underlying cause of lightheadedness and to minimize the risk of further injury or complications.
From the Research
Initial Assessment and Workup
The patient presents with lightheadedness, but denies passing out, dizziness, chest pain, or shortness of breath. Given her age and symptoms, a thorough workup is necessary to determine the cause of her lightheadedness.
- The patient's EKG shows sinus rhythm with premature atrial complexes, a rate of 77, and a QT interval of 445 ms, which is within normal limits.
- A complete blood count (CBC) may be useful in assessing for underlying conditions such as anemia, infection, or inflammation, as discussed in 2 and 3.
- A basic metabolic panel (BMP) can help evaluate electrolyte imbalances, renal function, and acid-base homeostasis, as mentioned in 4.
- Consideration of the patient's age and presentation, a workup for generalized weakness, as outlined in 5, may be relevant, including laboratory and imaging tests.
Additional Testing
- Given the patient's denial of chest pain or shortness of breath, but considering her age and presentation, a workup for heart failure, as discussed in 6, may include:
- Electrocardiogram (already performed)
- Complete blood count (CBC)
- Basic metabolic profile (BMP)
- Liver function tests
- Troponin
- Brain natriuretic peptide (BNP)
- Chest radiograph
- Point-of-care ultrasound to assess for B-lines, cardiac function, and inferior vena cava size
Considerations
- The patient's symptoms and age suggest the need for a thorough evaluation to determine the cause of her lightheadedness.
- A wide differential diagnosis should be considered, including cardiac, neurological, and metabolic causes.
- The workup should be tailored to the patient's specific symptoms and medical history, as discussed in 5 and 6.