Differential Diagnosis

The patient's presentation of frequent epistaxis, decline in mobility and balance, appetite, and cognitive function, along with a recent history of bilateral pulmonary embolism, suggests a complex underlying condition. Here's a categorized differential diagnosis:

• Single Most Likely Diagnosis

  • Cancer (e.g., lung, pancreatic, or other metastatic cancers): The combination of weight loss, decline in mobility and balance, decreased appetite, cognitive decline, and recurrent epistaxis could indicate an underlying malignancy. The recent bilateral pulmonary embolism further supports this, as cancer increases the risk of thromboembolic events.

• Other Likely Diagnoses

  • Chronic kidney disease or renal failure: Could explain the epistaxis (due to uremic platelet dysfunction), decreased appetite, and possibly the cognitive decline. However, it doesn't directly explain the pulmonary embolism without other risk factors.
  • Chronic liver disease: Liver dysfunction can lead to coagulopathy, explaining the epistaxis, and can also contribute to cognitive decline (hepatic encephalopathy). The decline in mobility and appetite could be related to liver disease, but the direct link to pulmonary embolism is less clear.
  • Vasculitis (e.g., Wegener's granulomatosis): Could explain the epistaxis and pulmonary symptoms, but the cognitive decline and mobility issues would be less typical presentations.

• Do Not Miss Diagnoses

  • Infectious endocarditis: Although less likely given the other symptoms, it could explain the embolic events (including pulmonary embolism) and possibly the epistaxis if there's associated vasculitis or immune complex deposition. Cognitive decline could occur due to embolic events affecting the brain.
  • Antiphospholipid syndrome: This condition can cause thrombosis (including pulmonary embolism), and some patients may experience cognitive decline. Epistaxis could be related to thrombocytopenia or vasculopathy.
  • Disseminated intravascular coagulation (DIC): Could explain the epistaxis and pulmonary embolism due to consumption of clotting factors and platelets. However, the cognitive decline and mobility issues would be less direct consequences.

• Rare Diagnoses

  • Amyloidosis: Could potentially explain the diverse symptoms, including epistaxis (due to vascular amyloid deposits), cognitive decline, and possibly the pulmonary embolism if there's associated cardiac amyloidosis leading to immobility and thrombosis.
  • Scurvy (Vitamin C deficiency): Although rare in developed countries, could explain the epistaxis (due to poor collagen synthesis affecting blood vessel integrity), decreased mobility (due to joint pain), and possibly some cognitive symptoms. However, it doesn't directly explain the pulmonary embolism.