Differential Diagnosis

The patient presents with a complex set of symptoms following a concussion, including severe migraines, bruising, extreme fatigue, and a strong smell in her urine, along with various abnormal laboratory results. The differential diagnosis can be categorized as follows:

• Single Most Likely Diagnosis

  • Post-Concussive Syndrome (PCS): Given the history of concussion 5 months prior, the patient's symptoms of severe migraines, extreme fatigue, and possibly the bruising (if related to easy bruising or a manifestation of her perception due to PCS) could be attributed to PCS. The strong smell in her urine might be related to another condition but could also be a subjective complaint in the context of PCS, where patients may experience a variety of somatic complaints.

• Other Likely Diagnoses

  • Hypothyroidism: With a TSH of 0.13, which is lower than the normal range, this could indicate hyperthyroidism rather than hypothyroidism. However, symptoms like fatigue and possibly the migraines could be related. It's essential to consider the clinical context and potentially re-evaluate thyroid function.
  • Vitamin Deficiencies: The low MCHC (mean corpuscular hemoglobin concentration) could indicate a vitamin deficiency, such as vitamin B12 or iron deficiency, which could also contribute to fatigue and possibly the bruising.
  • Coagulopathy: A high PTT (partial thromboplastin time) suggests a problem with the intrinsic coagulation pathway, which could explain the bruising. This could be due to a variety of causes, including vitamin K deficiency, liver disease, or specific coagulation factor deficiencies.

• Do Not Miss Diagnoses

  • Bleeding Disorder: Given the high PTT and bruising, it's crucial to rule out a bleeding disorder, such as hemophilia A or B, or factor deficiencies, which could be life-threatening if not identified and managed properly.
  • Liver Disease: The combination of low MCHC, high PTT, and possibly the strong smell in the urine (if indicative of liver dysfunction leading to an abnormal metabolite in the urine) necessitates consideration of liver disease, which could be due to various causes, including viral hepatitis, autoimmune hepatitis, or cirrhosis.
  • Thyroid Storm: Although the TSH is low, suggesting hyperthyroidism, the clinical presentation does not strongly support thyroid storm. However, given the potential for severe consequences, it should be considered, especially if there are other symptoms such as tachycardia, fever, or significant agitation.

• Rare Diagnoses

  • Porphyrias: This group of disorders can present with a variety of symptoms, including neurological manifestations (like migraines), psychiatric symptoms, and abdominal pain. Some forms of porphyria can cause urine to darken upon standing due to the presence of porphyrins, which might be perceived as a strong smell.
  • Systemic Mastocytosis: This condition involves the proliferation of mast cells and can lead to a wide range of symptoms, including easy bruising, fatigue, and possibly neurological symptoms. However, it is quite rare and would require specific diagnostic testing for confirmation.