Seen in the ED: An Elderly Man Feels Dizzy Doing Dishes

History of present illness. An elderly man was washing dishes when he became very dizzy and almost fainted. He was a poor historian and there was a language barrier requiring an interpreter, but he seemed to endorse symptoms of both vertigo and near-syncope as well as "a funny feeling in his chest" during the episode, which lasted about 5-10 minutes. He denies pain, fever, cough, headache, or other symptoms and feels fine now.

Vital signs & physical examination. Vital signs were normal although the systolic BP was significantly different—by >20 mm Hg—between arms. The rest of the physical exam, including the HINTS exam, Romberg, gait, and orthostatic measures were all normal.

Initial Diagnostic Testing

  • CBC: normal
  • Chem-7: normal
  • Troponin & ECG: normal
  • Imaging: see CT chest below

What is the most likely diagnosis?

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