Dishwasher Case Study

SUBJECTIVE
He presents for evaluation of episodes of feeling like he is going to pass out. He had his first episode last April or May when he was working in the kitchen loading the dishwasher. He describes it as a feeling that his "whole body got tingly. He initially wondered if it was related to the fact that he had been sleeping during the day and only eating one meal every 24 hours. More recently, however, he has been having more frequent episodes. The most recent one was in the evening of 11/14. He was preparing to go in the shower when he started feeling somewhat dizzy. While he was in the shower, his vision started to go dark. His body felt tingly, his legs felt weak. He dropped his towel, bent down to grab it and it slipped through his hands three times before he could grasp it. He sat down and gradually began to feel better. He wonders if these episodes could be due to his medications for a couple reasons: There were three days when he did go to the pill window to take his nortriptyline and his symptoms were
Neurologic exam: Pupils are equally round and reactive to light. Extraocular movements are full. There is normal strength for the _____ in facial musculature, normal palate rise and tongue movement. Strength in the trapezius in the upper and lower extremities is normal and symmetrical bilaterally. Deep tendon reflexes are 2+ biceps, triceps, brachioradialis, and patellar. I cannot really elicit an Achilles reflex on either side. Neuro exam: Romberg test is negative. Gait is normal. He does have a mild fine tremor of the hands bilaterally, which he states is relatively new. Lungs are clear to auscultation throughout. Heart: S1, S2 normal. No murmur, rubs, or gallops. Auscultation in the neck reveals a definite carotid bruit on the left, which on my exam does not appear to be a referred murmur. Reviewed his lab. He has any blood work since