Nu627U4peerresponseMarla

Positive Information

Constant dizziness yesterday, resolved after taking a shower
Elevated BP-patient reported 189/112 at local pharmacy
Family history of DM, HTN, CAD, & breast CA

Negative Information

No recurrent dizziness or vertigo
No lightheadedness, N/V, headache, chest pain, SOB, or blurred vision
No unsteadiness, weakness, numbness, or tingling
No ear pain, fullness, or visual changes
No past elevated BP
No stress, tobacco, or ETOH use
No medication use
ROS was unremarkable with no significant findings related to the patientâ€™s symptoms of dizziness or elevated BP

Missing Information

How long did the dizziness last?
What were you doing when you experienced the dizziness?
Have you experienced dizziness or similar episodes in the past?
Was the dizziness affected by head movements or position changes?
Did you notice any other symptoms at the time? (palpitations, sweating)
Is there a history of edema, chest pain, or palpitations?
Is there a history of headaches or visual disturbances with high BP?
Do you monitor your BP at home?
What does your diet look like? Water intake?
Are you physically active?
Have you experienced any recent significant changes? Stress?
Have you noticed feeling dizzy when moving from different positions? (standing, sitting, lying)
Any recent illnesses?
Have you had a previous EKG or other cardiac workup? Lab work?
Do you take any OTC medications?

Differential Diagnoses

Hypertension-New Onset: This patient does not have a prior history of HTN, but she experienced a single episode of elevated blood pressure (189/112) at a local pharmacy, which was associated with dizziness that resolved after a shower. This elevated reading likely represents a hypertensive urgency (HU), given the significant spike without any acute signs of target organ damage (Benenson et al., 2023). Patients with hypertensive urgency may be entirely asymptomatic or may exhibit symptoms such as headaches, palpitations, shortness of breath, dizziness, and/or nausea (Benenson et al., 2023). Her blood pressure normalized at the clinic (129/86), and she reports no previous issues with high blood pressure. However, her family history is significant for cardiovascular conditions, as her sister has both HTN and diabetes, and her maternal grandfather passed away from CAD at age 78. These familial risk factors suggest that she may be predisposed to HTN and cardiovascular issues, warranting close monitoring and further evaluation.
Benign Paroxysmal Positional Vertigo (BPPV): BPPV typically presents with dizziness that is triggered by specific head movements (Madrigal et al., 2024). The prevalence of BPPV increases with age, affecting approximately 2.4% of the population over their lifetime (Madrigal et al., 2024). Although this patient did not report classic vertigo symptoms, her episode of dizziness could still be attributed to BPPV, especially if positional changes were a factor.
Hyperthyroidism: As individuals age, the presentation of hyperthyroidism may differ significantly, often resulting in fewer noticeable symptoms compared to younger patients (Chaker et al., 2024). This phenomenon can be attributed to the milder forms of the disease commonly observed in older adults. The presence of cardiac irregularities such as atrial fibrillation or atrial flutter, along with symptoms like palpitations and alterations in mood, should also prompt consideration of hyperthyroidism (Chaker et al., 2024).

Priority Diagnosis

Hypertension-The primary diagnosis for this patient is HTN, due to her elevated blood pressure reading of 189/112 mmHg at the pharmacy, despite her current BP being normal at the clinic. According to the American College of Cardiology (ACC) and the American Heart Association (AHA) guidelines, HTN is defined as having a systolic BP of 130 mmHg or higher or a diastolic BP of 80 mmHg or higher (Lindsey, 2023). The patient has no prior history of elevated blood pressure, making this isolated episode noteworthy. Also, her family history reveals a predisposition to cardiovascular diseases, including HTN and CAD, which increases her risk profile. Although she reports no ongoing symptoms of dizziness or lightheadedness, her single episode of elevated blood pressure aligns with the ACC/AHA’s classification of HTN, indicating the need for further evaluation and management to prevent future complications.

Plan

Diagnostics: A comprehensive diagnostic evaluation is essential to confirm the diagnosis of HTN and identify any underlying causes. Blood pressure monitoring should be done through ambulatory blood pressure monitoring (ABPM). ABPM is considered the gold standard for diagnosing hypertension and evaluating 24-hour blood pressure, offering key data that cannot be obtained through other methods of blood pressure measurement (Kario et al., 2021). ABPM is crucial for both the diagnosis and management of HTN and is widely recognized as an essential component of best clinical practice in HTN management (Kario et al., 2021). Laboratory tests such as a CBC, BMP, lipid profile, thyroid function tests, and UA are crucial to assess kidney function, electrolyte levels, and potential thyroid disorders that may contribute to HTN. Red Cell Distribution Width (RDW) is a measure of the variation in the size of red blood cells and recent studies suggest that elevated RDW may be associated with increased cardiovascular risk, including hypertension (Seo & Lee, 2022). An EKG is needed to help evaluate cardiac health. Depending on the findings, an echocardiogram may be warranted to assess heart structure and function. A neurological assessment, including a CT scan or MRI of the head, may be necessary given her episode of dizziness. Reviewing any home blood pressure records can also provide valuable insights into her blood pressure trends, guiding appropriate treatment and management strategies.

Therapeutics: For this patient, the therapeutic plan should begin with non-pharmacologic interventions focusing on lifestyle modifications. Encourage the patient to adopt a low-sodium DASH diet to help manage blood pressure naturally, along with increasing physical activity to at least 30 minutes of moderate exercise five days per week. Proper hydration is also key to preventing dizziness, particularly if symptoms are positional. If lifestyle changes alone do not adequately control her blood pressure, pharmacologic interventions should be considered. At that point, I would begin with Lisinopril 10mg po daily along with continued lifestyle modifications.

Education: Lifestyle changes, such as following the DASH diet, increasing physical activity, and maintaining a healthy weight should be discussed. The patient should be educated on the importance of monitoring blood pressure at home, keeping a detailed log, and bringing it to future appointments for review. Education on the signs and symptoms of hypertensive complications, including headaches, chest pain, or vision changes, is essential so she can seek immediate care if these occur. Given her family history of HTN and CAD, regular check-ups with a healthcare provider are crucial. Screening for other cardiovascular risks, such as cholesterol levels and potential diabetes, is also important. I would also explain the importance of hydration and avoiding rapid changes in position to prevent dizziness, which could be related to benign positional vertigo or blood pressure fluctuations.

Consultation: Cardiology pending diagnostic results, ENT for dizziness if cardiac workup is unremarkable

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