Differential Diagnosis for 37-year-old Patient with Bilateral Flank Pain and Other Symptoms

The patient presents with a complex array of symptoms including bilateral flank pain suggestive of renal involvement, a deep ache near McBurney's point (indicative of possible appendicitis), substernal ache, slight dry cough, difficulty taking a full deep breath, and fever. These symptoms can be indicative of several conditions, which can be categorized as follows:

• Single Most Likely Diagnosis

  • Pyelonephritis or Sepsis: The combination of bilateral flank pain, fever, and the potential for respiratory symptoms could indicate a severe urinary tract infection (pyelonephritis) that may have progressed to sepsis, especially if the patient's condition is severe. The presence of a deep ache near McBurney's point could also suggest a possible appendicitis, but the bilateral flank pain leans more towards a renal issue.

• Other Likely Diagnoses

  • Pneumonia: The slight dry cough and difficulty taking a full deep breath could suggest pneumonia, especially if the patient has a fever. Pneumonia can sometimes cause referred pain to the abdomen or flank area, especially if the pneumonia is located at the lung bases.
  • Appendicitis with Perforation: Although the primary symptom suggesting appendicitis is the pain near McBurney's point, the presence of fever and flank pain could indicate a perforated appendix that has led to peritonitis, which might cause more widespread abdominal pain.
  • Pulmonary Embolism (PE): The substernal ache and difficulty breathing could be indicative of a pulmonary embolism, especially if the patient has risk factors for deep vein thrombosis (DVT). However, the flank pain and fever would be less typical for PE.

• Do Not Miss Diagnoses

  • Sepsis from Any Source: Regardless of the primary diagnosis, sepsis is a life-threatening condition that requires immediate recognition and treatment. The presence of fever, potential respiratory distress, and abdominal pain could all be indicative of sepsis.
  • Cardiac Conditions (e.g., Myocarditis, Pericarditis): The substernal ache could also suggest cardiac involvement, such as myocarditis or pericarditis, both of which can present with fever and chest pain. These conditions are less likely given the abdominal symptoms but are critical not to miss.
  • Pneumothorax: A spontaneous pneumothorax could cause sudden onset of chest pain and shortness of breath, and while less likely given the flank pain, it's a condition that would require immediate intervention.

• Rare Diagnoses

  • Familial Mediterranean Fever: This is a rare genetic disorder that can cause recurrent episodes of fever and severe abdominal, chest, or joint pain. It's less likely but could be considered if other diagnoses are ruled out and there's a relevant family history.
  • Ehlers-Danlos Syndrome with Vascular Complications: Although very rare, Ehlers-Danlos syndrome can lead to vascular complications such as aortic dissection, which could present with severe chest and abdominal pain. This would be an extremely rare consideration but one that could be life-threatening if missed.