In a 60‑year‑old woman with hypertension, poorly controlled type‑2 diabetes mellitus, chronic kidney disease, on valsartan (angiotensin II receptor blocker), amlodipine (calcium channel blocker), insulin degludec/insulin aspart (Ryzodeg), rosuvastatin (HMG‑CoA reductase inhibitor), dapagliflozin (SGLT2 inhibitor), pioglitazone (thiazolidinedione), trimetazidine (anti‑ischemic metabolic agent), and apixaban (direct factor Xa inhibitor), presenting with a 10‑hour history of spinning vertigo and light‑headedness at rest worsened by forward bending, a small bruise on the right medial arm, sinus bradycardia, a low‑grade blowing systolic murmur, hyperglycemia, low MCH (hypochromic anemia), lymphocytosis, and low‑normal creatinine, what is the most likely diagnosis and what immediate and short‑term management steps should be taken?

Acute Vertigo with Sinus Bradycardia in a Diabetic Patient on Multiple Medications

Most Likely Diagnosis

This patient most likely has benign paroxysmal positional vertigo (BPPV) or peripheral vestibular dysfunction, with sinus bradycardia as a secondary finding that requires medication review. The spinning vertigo aggravated by bending, absence of focal neurological deficits, and normal vital signs except bradycardia point away from central causes or hypertensive emergency 1.

Critical Immediate Assessment

Rule Out Central Causes and Hypertensive Emergency

• Perform fundoscopic examination immediately to exclude papilledema or hypertensive retinopathy, as the patient has poorly controlled diabetes (HbA1c 9.2%) and multiple cardiovascular risk factors 2, 1.
• Assess for focal neurological deficits, altered mental status, or severe persistent headache with visual disturbances, which would indicate hypertensive emergency requiring ICU admission 1.
• The current BP of 130/70 mmHg does not meet criteria for hypertensive emergency (>180/120 mmHg) and is actually at goal for a diabetic patient 2.

Address the Sinus Bradycardia

• The sinus bradycardia on ECG warrants immediate evaluation of the patient's beta-blocker status and heart rate. While not mentioned in the medication list, the cardiac murmur and bradycardia raise concern 2.
• Measure resting heart rate carefully over 30 seconds to confirm bradycardia and assess if symptomatic (dizziness may be related) 2.
• The Grade 2/6 blowing systolic murmur heard at multiple intercostal spaces requires echocardiography to evaluate for valvular disease, particularly given the patient's cardiovascular risk profile 2.

Vertigo-Specific Evaluation

Perform Dix-Hallpike Maneuver

• Execute the Dix-Hallpike test to diagnose BPPV, the most common cause of episodic spinning vertigo aggravated by position changes.
• If positive (reproduces vertigo with nystagmus), treat with Epley maneuver immediately in the clinic.

Exclude Medication-Related Causes

• Review the apixaban dose (5mg) in context of the small bruise – while a single small bruise is not alarming, ensure no signs of bleeding that could cause orthostatic symptoms.
• Check orthostatic vital signs (BP and heart rate supine, then after 1 and 3 minutes standing) given multiple antihypertensive medications and diabetes 2, 3.

Management of Poorly Controlled Diabetes

Immediate Glycemic Concerns

• The HbA1c of 9.2% with fasting glucose 7.45 mmol/L (134 mg/dL) and 4+ glucosuria indicates severely inadequate diabetes control despite multiple agents (insulin, SGLT2 inhibitor, pioglitazone) 2, 4.
• Patients with poorly controlled diabetes have significantly higher cardiovascular risk and more cardiovascular risk factors than those with good control 4.
• Increase insulin degludec/aspart (Ryzodeg) dose from 10 units – this is a very low dose for someone with HbA1c 9.2% 2.

Optimize Diabetes Medications

• Continue dapagliflozin 10mg as it provides nephroprotection (eGFR appears adequate based on low-normal creatinine 47.8 μmol/L) and reduces cardiovascular events 2.
• The SGLT2 inhibitor dapagliflozin is specifically recommended for patients with eGFR 30 to <90 mL/min/1.73m² and reduces renal endpoints 2.
• Consider adding or increasing GLP-1 receptor agonist (liraglutide or semaglutide) as these provide nephroprotection and cardiovascular benefits in type 2 diabetes 2.

Blood Pressure Management Optimization

Current Regimen Assessment

• The patient is on appropriate first-line agents for diabetic hypertension: valsartan (ARB), amlodipine (CCB), with BP at goal 130/70 mmHg 2.
• Target BP for diabetic patients should be <130/80 mmHg, which this patient has achieved 2.
• Valsartan and amlodipine both reduce oxidative stress in type 2 diabetic patients with hypertension and provide nephroprotection 5, 6, 7.

Consider Medication Adjustment

• If bradycardia is symptomatic and contributing to dizziness, consider reducing or holding amlodipine temporarily while evaluating the cardiac murmur 2.
• Do NOT discontinue valsartan – RAAS blockers are specifically recommended for diabetic patients with or without proteinuria for nephroprotection 2.

Anemia Evaluation

Address Hypochromic Anemia

• The low MCH (26 pg, normal 27-32) suggests hypochromic anemia, likely iron deficiency 2.
• Check complete iron studies (serum iron, TIBC, ferritin, transferrin saturation) to confirm iron deficiency.
• Iron deficiency contributes to fatigue and may worsen dizziness 2.
• If ferritin <100 μg/L or ferritin 100-299 μg/L with transferrin saturation <20%, initiate iron replacement 2.

Immediate Next Steps Algorithm

1. Perform Dix-Hallpike maneuver → If positive, treat with Epley maneuver
2. Check orthostatic vital signs → If positive drop (>20 mmHg systolic or >10 mmHg diastolic), adjust antihypertensives 2
3. Fundoscopic examination → If papilledema or hemorrhages, escalate care 1
4. Order echocardiogram for cardiac murmur evaluation 2
5. Order iron studies for hypochromic anemia 2
6. Increase insulin dose and consider adding GLP-1 RA for HbA1c 9.2% 2
7. Schedule diabetes education – structured group programs improve glycemic control and reduce HbA1c 2

Short-Term Follow-Up (Within 2-4 Weeks)

• Recheck HbA1c in 3 months after insulin adjustment 2.
• Monitor BP monthly until diabetes control improves, as poorly controlled diabetes is associated with higher BP 2, 4.
• Repeat orthostatic vitals if medication adjustments made 3.
• Follow up iron studies and hemoglobin after 4-6 weeks of iron replacement if initiated 2.
• Echocardiogram results review – if valvular disease confirmed, adjust antihypertensive strategy accordingly 2.

Critical Pitfalls to Avoid

• Do not attribute all dizziness to hypertension when BP is actually well-controlled at 130/70 mmHg 2, 1.
• Do not discontinue RAAS blockade (valsartan) in diabetic patients – it is essential for nephroprotection regardless of current creatinine 2, 7.
• Do not ignore the cardiac murmur – requires echocardiographic evaluation before attributing symptoms solely to BPPV 2.
• Do not accept HbA1c 9.2% as adequate control – this significantly increases cardiovascular risk and requires aggressive management 2, 4.
• Avoid excessive BP lowering below 120/70 mmHg in elderly diabetic patients, especially if diastolic BP approaches 60 mmHg 3.