Differential Diagnosis
The patient presents with a complex array of symptoms including abdominal pain, vomiting, diarrhea, fever, burning micturition, chest pain, and shortness of breath, alongside a history of Type 2 Diabetes Mellitus, old CVA, left PUJ stenosis with hydronephrosis, and being on clopidogrel. The clinical findings and investigations provide crucial clues towards narrowing down the differential diagnoses.
Single Most Likely Diagnosis
- Sepsis: The combination of fever, abdominal pain, vomiting, diarrhea, and the presence of burning micturition (possibly indicating a urinary tract infection) in a patient with a history of left PUJ stenosis with hydronephrosis, suggests an infectious process. The patient's fluctuating blood pressure, reduced ejection fraction (EF 33%), and signs of respiratory distress (fine basal crepitations, SOB) further support the diagnosis of sepsis, likely originating from a urinary source given the patient's history.
Other Likely Diagnoses
- Acute Coronary Syndrome (ACS): Although the troponin is negative, the patient's chest pain, history of CVA, and being on clopidogrel (indicating atherosclerotic disease), along with ECG changes (Q waves in V1–V2, minimal ST depression in inferior leads), make ACS a consideration. However, the negative troponin and the clinical context (more suggestive of sepsis) make it less likely.
- Congestive Heart Failure (CHF): The reduced EF, hypokinesia in multiple walls, mild MR, and Grade II diastolic dysfunction are indicative of heart failure. The patient's symptoms of shortness of breath and fine basal crepitations could be attributed to CHF, especially with a dilated IVC and elevated PASP. However, the acute onset of symptoms and the presence of fever and abdominal symptoms point more towards an acute infectious process.
- Pulmonary Embolism (PE): Although less likely given the clinical context, the sudden onset of chest pain and shortness of breath could suggest PE, especially in a patient with risk factors for thromboembolism (immobility due to CVA, possible dehydration from vomiting and diarrhea).
Do Not Miss Diagnoses
- Aortic Dissection: The chest pain and fluctuating blood pressure could be indicative of an aortic dissection, a diagnosis that is critical not to miss due to its high mortality rate. However, the absence of classic symptoms (tearing chest pain, differential blood pressures in limbs) and specific diagnostic findings makes this less likely.
- Mesenteric Ischemia: Given the patient's abdominal pain, vomiting, and history of atherosclerotic disease (CVA, on clopidogrel), mesenteric ischemia is a critical diagnosis not to miss, as it can lead to bowel infarction and has a high mortality rate if not promptly treated.
Rare Diagnoses
- Infective Endocarditis: Although the patient has a history of heart disease (reduced EF, MR), the absence of specific findings such as new regurgitant murmurs or embolic phenomena makes this diagnosis less likely.
- Vasculitis: The combination of abdominal pain, fever, and history of CVA could theoretically suggest a vasculitic process, but the lack of specific findings (e.g., skin rash, elevated inflammatory markers, specific autoantibodies) and the presence of more straightforward explanations for the patient's symptoms make this a rare consideration.