Differential Diagnosis
The patient's presentation is complex, involving multiple systems. The differential diagnoses can be categorized as follows:
Single most likely diagnosis
- Acute Kidney Injury (AKI) with Obstruction: The patient's history of anuria, reduced urine output, dysuria, hematuria, flank pain, and frothuria, along with abdominal distension and bilious vomiting, suggests an obstructive cause leading to acute kidney injury. The recent history of STEMI and ADHF, along with chronic alcohol use, could contribute to renal dysfunction.
Other Likely diagnoses
- Chronic Kidney Disease (CKD) Progression: Given the family history of CKD, the patient's symptoms of reduced urine output, and past requirement for hemodialysis, progression of CKD is a likely consideration.
- Intestinal Obstruction: Sudden-onset colicky abdominal pain, recurrent bilious vomiting, and abdominal distension are classic signs of intestinal obstruction, which could be causing the patient's acute symptoms.
- Cardiovascular Disease: The patient's history of STEMI and ADHF, along with symptoms of progressive breathlessness, suggests ongoing cardiovascular disease that could be contributing to the patient's renal issues and overall clinical picture.
Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
- Sepsis: Although not immediately apparent, the combination of abdominal symptoms, reduced urine output, and overall clinical deterioration could indicate sepsis, particularly if there's an obstructed or infected system (e.g., urinary tract or bowel).
- Abdominal Aortic Aneurysm (AAA): The patient's history of intermittent claudication and abdominal pain could suggest an AAA, especially in the context of chronic smoking. Rupture of an AAA would be catastrophic.
- Pulmonary Embolism (PE): Given the patient's progressive breathlessness and past history of cardiovascular disease, a PE should be considered, as it could lead to significant morbidity and mortality if not promptly diagnosed and treated.
Rare diagnoses
- Retroperitoneal Fibrosis: This condition could cause obstructive uropathy leading to renal failure and might explain some of the patient's abdominal and urinary symptoms.
- Amyloidosis: Given the patient's chronic disease history and multi-system involvement, amyloidosis could be a rare but unifying diagnosis, affecting the kidneys, heart, and potentially other systems.