Given these changes from the original case, what is your diagnosis?
What is your diagnostic explanation?
As compared to the long case, this patient is a 45 year old woman who presents with feelings of dizziness for the past two weeks.
HPI: The dizziness is described as light-headed and only lasts for a few minutes. It has been occurring most mornings for the past two weeks and occasionally throughout the day. She once had it occur after getting into an argument with her daughter about doing chores. The patient has also noticed morning headaches, which are present upon awakening and mainly localize to the occipital region. She’s been taking more Sumatriptan than usual because she has had several regular and vestibular migraines. However, the triptans are not helping these early morning headaches or occasional dizziness. The patient has also noticed low energy for the past month and has struggled to get tasks accomplished because of fatigue.
PMH: Panic disorder treated with SSRIs and migraines treated with Sumatriptan. The patient also mentions she had a BP screening 4 months ago at a health fair which revealed the “first number was around 190.”
Physical Exam –
VS: Height 64” (162cm), Weight 123lbs (55.8kg), BMI 21.1 HR 95, BP 208/102 left arm and 210/100 in the right arm, RR 14, Temp 98.6, O2 saturation 100% on room air.
Cardiovascular exam reveals regular rate and rhythm, S1 and S2 heard. No murmurs/clicks/gallops rubs appreciated. No carotid/renal bruits, no abnormal pulsation in the abdomen, dorsalis pedis and radial arteries are bounding but equal bilaterally.
Respiratory exam shows occasional hacking cough, lungs clear to auscultation – no wheezes/rubs/rales/rhonchi.
Abdominal exam non-tender, non-distended active bowel sounds.
Opthalmic exam shows no papilledema but copper wiring and AV nicking are present. Dix-Hallpike and Rhomberg signs are absent. No muscle weakness, problems with gait, cranial nerve defects, or sensory loss is apparent.
Tests:
- CMP is within normal limits except for creatinine at 1.3mg/dl and BUN at 15mg/dl (both elevated from last CMP at birth of her daughter 17 years ago = 0.9mg/dl and 8 mg/dl)
- Urinalysis shows 1+ protein and no other abnormalities
- CBC shows Hgb 15g/dl of Hct of 43%
- Renal arteriogram shows no constrictions or abnormalities
- EKG – see below
