Differential Diagnosis for Hypotension, Vertigo, Headache, and Hematemesis

• Single most likely diagnosis:
  • Posterior Reversible Encephalopathy Syndrome (PRES) with secondary hemorrhage: This condition is characterized by headache, vertigo, and visual disturbances due to hypertension, but in this case, the patient has hypotension. However, the presence of hematemesis could indicate a gastrointestinal bleed possibly triggered by a hypertensive crisis that was not captured, or a complication of another underlying condition.
• Other Likely diagnoses:
  • Subarachnoid Hemorrhage (SAH): Although the patient is hypotensive, SAH can present with sudden headache, vertigo, and in severe cases, can lead to hematemesis due to increased intracranial pressure causing vomiting blood.
  • Gastrointestinal Bleed: This could be a primary cause of hypotension and hematemesis, with vertigo and headache being secondary to hypovolemia and anemia.
  • Meningitis: Could present with headache, vertigo, and in severe cases, hematemesis, especially if there's an associated syndrome like Waterhouse-Friderichsen syndrome in the context of Neisseria meningitidis infection.
• Do Not Miss (ddxs that may not be likely, but would be deadly if missed.):
  • Aortic Dissection: Although less likely given the absence of typical chest pain, it can cause hypotension, vertigo (if the dissection involves the carotid arteries), headache, and hematemesis if there's an associated aortic rupture leading to bleeding into the gastrointestinal tract.
  • Pituitary Apoplexy: A medical emergency that can present with sudden headache, vertigo, and visual disturbances. Hematemesis could occur due to acute adrenal insufficiency leading to gastrointestinal bleeding.
  • Ruptured Aneurysm: Similar to SAH, but with a more focal neurological deficit depending on the aneurysm's location. Hypotension and hematemesis could occur due to the severity of the bleed.
• Rare diagnoses:
  • Ehlers-Danlos Syndrome with associated vascular rupture: This could lead to aortic dissection, SAH, or gastrointestinal bleeding, presenting with the described symptoms.
  • Pheochromocytoma with associated hypertensive crisis and hemorrhage: Although the patient is described as hypotensive, pheochromocytoma can cause episodic hypertension leading to hemorrhage, and subsequent hypotension due to blood loss.
  • Vasculitis (e.g., Polyarteritis Nodosa): Could cause a wide range of symptoms including hypertension, gastrointestinal bleeding, and neurological symptoms due to vascular inflammation and rupture.