Geriatric Case Study

HK is an 83 young woman complaining of pruritic “hives” (small red bumps) one day ago on trunk and thighs accompanied by nausea and lightheadedness. Her left eyelid also became swollen. Symptoms occurred at rest and lasted two hours.
Unfortunately, we had no camera in the office during her initial. The swelling of her eyelid lasted a bit longer than the bumps on her trunk and thighs. Her lightheadedness represented presyncope.
She had many similar episodes in the past six months. During one episode, she had syncope and was hospitalized. She was diagnosed with orthostatic hypotension.
Past Medical History
Osteoarthritis: hip arthroplasty 10/04
Colon cancer stage II: 2000
fluoxetine (10mg daily)
fosamax (70mg weekly)
MVI daily
Her fluoxetine was begun recently, thinking that her recurrent presyncope could be caused by depression.
ROS: nausea/emesis and dizziness with pruritic rash, some memory impairment, no fevers, no headache, no palpitations, no chest pain or dyspnea
Social History
Her family believes that she has been under unusual emotional stress and believes that stress is contributing to her current presentation. She moved from her home to a life care community six months ago and has been anxious and unhappy.
Physical Examination
BP: 150/68 (not orthostatic)
Cardiac: regular rate in 80s, normal exam
Skin: patch of erythema on back and trunk beneath bra strap, erythema over beltline, red papules on lower anterior chest, ecchymoses on shoulders and legs. The rash seen on exam is different than the transient rash that she had one day ago.

  1. What are her 3 diagnoses (Identifies 3 or more differentials diagnoses and lists typical symptoms and presentation)?
  2. What diagnosis would constitute an emergency?

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