Differential Diagnosis

The patient's complex presentation of chest pain, neurological symptoms, and the incidental finding of a 2-millimeter cerebral aneurysm requires a broad differential diagnosis. The following categories organize potential diagnoses based on likelihood and severity:

• Single Most Likely Diagnosis
  • Migraine with Aura: The patient's description of severe migraines with associated symptoms such as hot sensations on the side of her face, vision loss, and hearing loss, along with the presence of a cerebral aneurysm, could suggest that her symptoms are related to migraines. The aneurysm might be an incidental finding, but it could also be related to her symptoms if it is causing or contributing to her migraines.
• Other Likely Diagnoses
  • Vestibular Migraine: Given the patient's symptoms of dizziness, nausea, and headache, along with the migraines, vestibular migraine is a possible diagnosis. This condition can cause vertigo and balance problems, which might explain some of her neurological symptoms.
  • Anxiety Disorder: The patient reports high anxiety and stress, particularly related to her personal life. This could contribute to or exacerbate her physical symptoms, including headaches and possibly even the perception of her other symptoms.
  • Hypertension: The patient mentions that she believes her stress raises her blood pressure. Hypertension could be a contributing factor to her symptoms, especially if it is uncontrolled, and could also be related to the development or rupture of the cerebral aneurysm.
• Do Not Miss Diagnoses
  • Ruptured Cerebral Aneurysm: Although the aneurysm is small (2 millimeters), any cerebral aneurysm has the potential to rupture, leading to a subarachnoid hemorrhage, which is a medical emergency. The patient's symptoms of sudden severe headache, nausea, and neurological deficits could be indicative of an aneurysmal rupture.
  • Stroke or Transient Ischemic Attack (TIA): The patient's symptoms of sudden weakness, confusion, difficulty speaking, and vision changes could indicate a stroke or TIA. These are medical emergencies that require immediate attention.
  • Temporal Arteritis: This condition, also known as giant cell arteritis, can cause headaches, vision loss, and hearing loss, among other symptoms. It is more common in older adults but should be considered, especially given the patient's complex presentation.
• Rare Diagnoses
  • Central Nervous System Vasculitis: This is a rare condition that involves inflammation of the blood vessels in the brain and spinal cord. It could explain some of the patient's neurological symptoms but would be less likely without other specific findings such as elevated inflammatory markers.
  • Mitochondrial Encephalomyopathy, Lactic Acidosis, and Stroke-like Episodes (MELAS): This is a rare mitochondrial disorder that can cause stroke-like episodes, headaches, and other neurological symptoms. It would be a consideration in patients with a personal or family history suggestive of mitochondrial disease.