Differential Diagnosis

The patient's presentation of listlessness, dull mid-epigastric pain, palpable nontender gallbladder, lower extremity edema, and a palpable cord on the right lower extremity suggests a complex clinical picture. Here's a categorized differential diagnosis:

• Single Most Likely Diagnosis

  • Pancreatic Cancer: The combination of dull mid-epigastric pain, a palpable nontender gallbladder (Courvoisier's sign), and the patient's history of alcohol and tobacco use disorder makes pancreatic cancer a strong consideration. The palpable cord could be indicative of a thrombophlebitis (Trousseau’s syndrome), which is sometimes associated with pancreatic cancer.

• Other Likely Diagnoses

  • Cholecystitis or Cholelithiasis: Although the gallbladder is nontender, gallstones could still be present and cause intermittent obstruction leading to pain. However, the presence of a palpable cord and significant lower extremity edema suggests a more complex condition.
  • Alcoholic Pancreatitis: Given the patient's alcohol use disorder, chronic pancreatitis is a possibility. However, the presence of a palpable cord and significant edema might suggest a more acute or severe process.
  • Deep Vein Thrombosis (DVT): The palpable cord on the right lower extremity could be indicative of a DVT, which could be primary or secondary to another condition like cancer.

• Do Not Miss Diagnoses

  • Pulmonary Embolism (PE): Although not directly suggested by the symptoms, the presence of lower extremity edema and a palpable cord (possible DVT) necessitates consideration of PE, especially given its potential lethality.
  • Abdominal Aortic Aneurysm: This condition could present with mid-epigastric pain and might be associated with a palpable abdominal mass, though it's less likely given the specific combination of symptoms.
  • Inferior Vena Cava (IVC) Obstruction: This could explain the lower extremity edema and might be associated with a malignancy, such as pancreatic cancer, or a thrombotic event.

• Rare Diagnoses

  • Retroperitoneal Fibrosis: A rare condition that could cause abdominal pain and lower extremity edema due to obstruction of the ureters or lymphatic vessels, but it's less likely given the specific symptoms.
  • Splenomegaly or Splenic Vein Thrombosis: Could be associated with pancreatitis or pancreatic cancer but would typically present with left upper quadrant pain and might not fully explain the lower extremity findings.