Differential Diagnosis for 75 yo Female with Syncopal Episode

The patient's presentation with a syncopal episode, weight loss, loss of appetite, and ongoing cough, along with her past medical history, suggests a complex differential diagnosis. The following categories organize potential diagnoses based on likelihood and urgency:

• Single Most Likely Diagnosis
  • Cardiac Causes: Given her history of atrial fibrillation, hypertension, CAD, and previous syncopal episodes, cardiac causes such as arrhythmias, cardiac ischemia, or heart failure are highly plausible. The syncopal episode could be related to these conditions, especially if there's an acute change in her cardiac status.
• Other Likely Diagnoses
  • Pulmonary Embolism: Although she's afebrile and without leukocytosis, her history of cough (sometimes productive), recent travel, and previous hospitalizations make pulmonary embolism a consideration, especially if she has risk factors for deep vein thrombosis.
  • Chronic Obstructive Pulmonary Disease (COPD) or Other Pulmonary Conditions: The ongoing cough and history of nodules on lung imaging could suggest a chronic pulmonary condition, potentially exacerbated by her recent travel and change in environment.
  • Gastrointestinal Causes: Her initial nausea after the buffet and subsequent loss of appetite and weight could indicate a gastrointestinal issue, such as gastroesophageal reflux disease (GERD), peptic ulcer disease, or even a malignancy, though the latter would be less likely without more specific symptoms.
• Do Not Miss Diagnoses
  • Pulmonary Tuberculosis (TB): Given the calcific granulomatous disease and lung nodules, TB is a critical diagnosis not to miss, especially if she has been exposed or has risk factors. The dry cough and weight loss are classic symptoms.
  • Lung Cancer: Although less likely without a smoking history provided, the presence of lung nodules and her age make lung cancer a diagnosis that must be considered and ruled out, especially if there's a significant change in her symptoms or imaging findings.
  • Infectious Endocarditis: With a history of atrial fibrillation and previous syncopal episodes, infectious endocarditis could be a life-threatening condition that needs to be ruled out, despite the lack of fever or leukocytosis at presentation.
• Rare Diagnoses
  • Sarcoidosis: This condition could explain the granulomatous disease and lung nodules but would be less likely without other systemic symptoms such as skin lesions, eye symptoms, or significant lymphadenopathy.
  • Lymphoma: Given the weight loss, loss of appetite, and lung nodules, lymphoma is a rare but possible diagnosis that would require further investigation, including biopsy of the nodules if accessible.

Each of these diagnoses requires careful consideration of the patient's history, physical examination, and diagnostic tests to determine the most appropriate next steps in management.