Differential Diagnosis
The patient's presentation is complex, with a range of laboratory and imaging findings. Here's a breakdown of potential diagnoses into categories:
Single Most Likely Diagnosis
- Diabetic Ketoacidosis (DKA): The patient's glucose level is significantly elevated at 318, with a high urine glucose level (>500), suggesting uncontrolled diabetes. The presence of ketones (indicated by the high anion gap suggested by the base excess -5 and the clinical context) and the metabolic acidosis (base excess -5) further support this diagnosis. The patient's prolonged stay on the garage floor could be due to altered mental status from DKA.
Other Likely Diagnoses
- Urinary Tract Infection (UTI): The urinalysis shows many bacteria, positive nitrite, and trace leukocyte esterase, indicating a UTI. This could be a contributing factor to the patient's condition, especially if it led to sepsis or contributed to the patient's altered mental status.
- Rhabdomyolysis: Although the CK level is elevated at 1786, which could indicate muscle damage from lying on the floor for an extended period, the absence of significant renal impairment (despite a slightly elevated BUN) makes this less likely as the primary diagnosis.
- Dehydration: The elevated BUN and the presence of metabolic acidosis could also suggest dehydration, which might have been exacerbated by the hyperglycemic state.
Do Not Miss Diagnoses
- Sepsis: Although the CBC is unremarkable, the presence of a UTI and the patient's overall condition (found on the floor, altered mental status) necessitate consideration of sepsis, which could be life-threatening if not promptly addressed.
- Cerebral or Spinal Injury: Despite negative CT scans of the head, lumbar, cervical, and thoracic regions, it's crucial not to miss any potential injury that could have occurred from the fall or prolonged positioning on the floor. Clinical correlation and possibly further imaging or neurological evaluation might be necessary.
- Cardiac Ischemia: Although the troponin is only slightly elevated (0.01), in the context of the patient's presentation, cardiac ischemia should be considered, especially given the stress of potential sepsis, DKA, or other acute conditions.
Rare Diagnoses
- Hypothyroidism: Although less likely, severe hypothyroidism can cause altered mental status and could potentially contribute to the patient's condition, especially if there's a history suggestive of thyroid disease.
- Adrenal Insufficiency: This is another rare condition that could present with altered mental status, hypotension, and potentially elevated glucose levels, although specific tests (e.g., cortisol levels) would be needed to diagnose this condition.