Differential Diagnosis
The patient presents with a complex medical history and multiple symptoms. Here's a differential diagnosis organized into categories:
- Single Most Likely Diagnosis
- Diabetic Ketoacidosis (DKA): The patient has a history of type 2 diabetes, took short-acting insulin, and presents with a glucose level of 500, lactic acidosis (lactic acid 4.2), and an elevated white blood cell count. These findings are consistent with DKA, which is a life-threatening complication of diabetes.
- Other Likely Diagnoses
- Sepsis: The patient has an elevated white blood cell count (19) with a high neutrophil count (9.8), which could indicate a bacterial infection. The presence of lactic acidosis also supports this diagnosis.
- Acute Coronary Syndrome: The patient has a significant history of coronary disease and presents with a feeling of being "off," which could be indicative of cardiac ischemia.
- Congestive Heart Failure (CHF) Exacerbation: The patient has a history of CHF and presents with a BNP of 104, which is elevated. This could indicate an exacerbation of CHF.
- Do Not Miss Diagnoses
- Septic Shock: Although the patient's blood pressure is not provided, the presence of lactic acidosis, elevated white blood cell count, and history of chronic diseases makes septic shock a potentially life-threatening diagnosis that should not be missed.
- Acute Kidney Injury: The patient has a history of chronic renal disease and presents with lactic acidosis, which could indicate acute kidney injury.
- Myocardial Infarction: The patient's history of coronary disease and presentation with a feeling of being "off" makes myocardial infarction a diagnosis that should not be missed.
- Rare Diagnoses
- Lactic Acidosis due to Metformin (PPO intake): Although the patient is taking metformin, lactic acidosis is a rare but potentially life-threatening side effect.
- Stress-Induced Hyperglycemia: The patient's stress response to a potential infection or other acute illness could be causing hyperglycemia.
- Other rare causes of lactic acidosis, such as thiamine deficiency or certain medications, should also be considered.