Differential Diagnosis
The patient's presentation is complex, involving cardiovascular and gastrointestinal symptoms. Here's a breakdown of the differential diagnosis:
Single most likely diagnosis:
- Acute right heart failure exacerbation due to possible myocardial infarction or further deterioration of cardiac function, compounded by potential gallbladder pathology. The recent consumption of a pork sandwich could be coincidental, but the development of right upper and right lower quadrant pain, along with a distended gallbladder and mild wall edema, suggests a possible link to the gastrointestinal symptoms. However, the primary concern is the cardiac status given the history of severe coronary artery disease and low ejection fraction.
Other Likely diagnoses:
- Cholecystitis or biliary colic: The distended gallbladder and right upper quadrant pain could suggest an acute gallbladder issue, possibly triggered by the fatty meal (pork sandwich).
- Cardiac ischemia or infarction: Given the patient's history of coronary artery disease, new or worsening cardiac symptoms could indicate further ischemia or infarction.
- Congestive heart failure exacerbation: The symptoms of right heart failure could be due to an exacerbation of the patient's known heart failure, potentially triggered by factors such as dietary indiscretion, medication non-adherence, or progression of the underlying disease.
Do Not Miss diagnoses:
- Pulmonary embolism: Although less likely given the gastrointestinal symptoms, pulmonary embolism could cause right heart failure and must be considered, especially if there are respiratory symptoms or risk factors for thromboembolism.
- Aortic dissection: This is a less common but potentially catastrophic condition that could present with acute pain and cardiovascular instability, although it's less directly linked to the gastrointestinal symptoms described.
- Mesenteric ischemia: Given the abdominal pain and potential for embolic events in the setting of cardiac disease, mesenteric ischemia is a critical diagnosis not to miss, as it requires prompt intervention.
Rare diagnoses:
- Cardiac tamponade: Although unlikely without specific symptoms like pulsus paradoxus or electrocardiographic changes, cardiac tamponade could cause cardiac compromise and must be considered in the differential of acute cardiac decompensation.
- Constrictive pericarditis: This condition could lead to right heart failure symptoms but is less likely without a history suggestive of pericardial disease.
- Arrhythmias: Certain arrhythmias, especially those causing a significant decrease in cardiac output, could present with symptoms of heart failure and must be ruled out with appropriate monitoring.