Differential Diagnosis
The patient's presentation and laboratory results suggest a complex clinical picture. Here's a differential diagnosis organized into the requested categories:
Single most likely diagnosis
- Diabetic Ketoacidosis (DKA): The patient's glucose level is significantly elevated at 318, and the urinalysis shows glucose >500, suggesting uncontrolled diabetes. The presence of ketones (although not directly measured) can be inferred from the metabolic acidosis (base excess -5) and the clinical context. 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 reveals 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 suggest muscle damage from prolonged immobilization, the absence of more significant renal impairment or other specific markers makes this less likely but still a consideration.
- Dehydration: The elevated BUN and BUN/creatinine ratio suggest dehydration, which could be due to the patient's diabetic state, UTI, or prolonged immobilization.
Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
- Sepsis: Although the CBC is unremarkable, the presence of a UTI and the patient's overall condition could mask early signs of sepsis. The slightly elevated d-dimer and the metabolic acidosis could also be indicative of a systemic infection.
- Acute Kidney Injury (AKI): The patient's dehydration, potential rhabdomyolysis, and sepsis could all contribute to AKI, which would be critical to identify and manage early.
- Cardiac Ischemia: Despite the troponin being only slightly elevated (0.01), it's essential to consider cardiac ischemia, especially given the patient's stress and potential for dehydration and electrolyte imbalances.
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, dehydration, and potentially life-threatening consequences if not recognized and treated promptly.