Differential Diagnosis

The patient's symptoms of feeling like she is on a dropping elevator, experiencing dizzy spells, and having low blood pressure suggest a range of possible diagnoses. Here is a categorized differential diagnosis:

• Single Most Likely Diagnosis

  • Vasovagal Syncope: This condition is characterized by a sudden drop in blood pressure, leading to reduced blood flow to the brain and a feeling of dizziness or fainting. The sensation of being on a dropping elevator could be a manifestation of the vertiginous feeling that precedes syncope. The trigger for vasovagal syncope can be stress, pain, or prolonged standing, among others.

• Other Likely Diagnoses

  • Orthostatic Hypotension: This condition involves a significant drop in blood pressure upon standing, which can lead to dizziness, lightheadedness, and fainting. The symptoms described could be consistent with orthostatic hypotension, especially if the patient experiences these symptoms when changing positions.
  • Benign Paroxysmal Positional Vertigo (BPPV): Although BPPV primarily causes vertigo, the intense dizzy spells could potentially lead to a feeling of being on a dropping elevator. However, BPPV is usually triggered by specific head movements and may not directly cause blood pressure to bottom out.
  • Anxiety or Panic Disorder: These conditions can cause significant physiological symptoms, including dizziness and a feeling of impending doom, which might be described as feeling like being on a dropping elevator. While blood pressure might not necessarily "bottom out," significant fluctuations can occur.

• Do Not Miss Diagnoses

  • Cardiac Arrhythmias: Conditions like atrial fibrillation or other arrhythmias can lead to significant drops in blood pressure and feelings of dizziness or fainting. Missing a cardiac arrhythmia could be life-threatening.
  • Myocardial Infarction or Cardiac Ischemia: Although less common in presenting with these exact symptoms, a heart attack can cause dizziness and fainting due to decreased cardiac output and subsequent drop in blood pressure.
  • Subclavian Steal Syndrome: A rare condition where there is a significant stenosis or occlusion of the subclavian artery, leading to a reversal of blood flow in the vertebral artery. This can cause vertigo, syncope, and arm fatigue, especially with arm exercise.

• Rare Diagnoses

  • Meniere's Disease: An inner ear disorder that involves vertigo, but it typically presents with hearing loss, tinnitus, and ear fullness, which are not mentioned in the scenario.
  • Autonomic Dysfunction: Conditions affecting the autonomic nervous system, such as pure autonomic failure or multiple system atrophy, can cause orthostatic hypotension and might lead to the described symptoms, though they are less common and usually part of a broader clinical picture.