Differential Diagnosis for 28-year-old Male with Acute Onset of Severe Abdominal Pain and Confusion

• Single most likely diagnosis:
  • Cocaine intoxication leading to acute abdominal and cardiovascular complications: The presence of a small packet of white powder (suggestive of cocaine), severe abdominal pain, confusion, dilated pupils, and significantly elevated blood pressure are all consistent with cocaine use. Cocaine can cause vasoconstriction, leading to bowel ischemia and abdominal pain, as well as hypertension and potential cardiovascular emergencies.
• Other Likely diagnoses:
  • Opioid overdose with secondary abdominal issues: Although less likely given the context (e.g., the presence of white powder, which could be cocaine, and the specific symptoms), opioid overdose can lead to altered mental status and abdominal pain. However, the severe hypertension and the specific findings of dilated pupils are less typical for opioid overdose.
  • Intestinal obstruction or other acute abdominal conditions: The severe abdominal pain, guarding, and rebound tenderness could suggest an acute abdominal condition such as an obstruction, but the context (e.g., the substances found, the acute onset of hypertension) points more towards a toxic or drug-related cause.
• Do Not Miss (ddxs that may not be likely, but would be deadly if missed):
  • Ruptured abdominal aortic aneurysm: Although less likely in a young individual, the severe abdominal pain and hypertension could be indicative of a ruptured aneurysm, which is a medical emergency.
  • Mesenteric ischemia: This could be a consequence of cocaine use (due to vasoconstriction) but also needs to be considered as a separate entity due to its high mortality rate if not promptly treated.
  • Intracranial hemorrhage: The confusion and altered mental status, combined with the severe hypertension, raise the possibility of an intracranial hemorrhage, which would be a medical emergency.
• Rare diagnoses:
  • Pheochromocytoma: A rare tumor that could cause episodic hypertension, abdominal pain, and other systemic symptoms, but it would be unusual for it to present so acutely and severely without prior episodes.
  • Acute porphyria: A group of rare genetic disorders that can cause severe abdominal pain, neurological symptoms, and psychiatric disturbances. However, the presence of substances and the specific pattern of symptoms make this less likely.