Differential Diagnosis for Female Patient MR

The patient presents with a 3-week history of cough and vomiting after meals, which has progressed to vomiting large amounts not related to food intake. Given her paraplegic status, several factors must be considered in the differential diagnosis.

• Single Most Likely Diagnosis

  • Gastroesophageal Reflux Disease (GERD): This condition is common, especially in patients with limited mobility. The vomiting after meals and the progression to more frequent vomiting could be indicative of GERD, exacerbated by her paraplegic condition which may affect gastric emptying and increase pressure on the stomach.

• Other Likely Diagnoses

  • Aspiration Pneumonia: Given the initial cough and progression of symptoms, aspiration pneumonia is a possibility, especially if the patient has been vomiting and then inhaling gastric contents into the lungs.
  • Gastric Outlet Obstruction: This could be due to various causes including ulcers, tumors, or bezoars, and would explain the vomiting, especially if it's not solely related to food intake anymore.
  • Urinary Tract Infection (UTI): In paraplegic patients, UTIs can present atypically, including with gastrointestinal symptoms due to autonomic dysreflexia or due to the infection itself causing systemic symptoms.

• Do Not Miss Diagnoses

  • Autonomic Dysreflexia: A life-threatening condition that can occur in patients with spinal cord injuries above T6. It can be triggered by a noxious stimulus below the level of injury, such as a full bladder or bowel, and presents with sudden onset of hypertension, headache, and potentially vomiting.
  • Pulmonary Embolism: Paraplegic patients are at increased risk of deep vein thrombosis and subsequent pulmonary embolism, which can present with cough and potentially vomiting if there's significant respiratory distress.
  • Bowel Obstruction: Although less common, bowel obstruction can occur and would need to be ruled out, especially if there's a history of abdominal surgery or other risk factors.

• Rare Diagnoses

  • Gastroparesis: A condition where the stomach takes too long to empty its contents, which can be due to various causes including diabetes, certain medications, or post-viral infections. It's less likely but could explain some of the gastrointestinal symptoms.
  • Cyclic Vomiting Syndrome: A rare condition characterized by recurrent episodes of severe vomiting, which could be considered if other diagnoses are ruled out.

Management

Management will depend on the diagnosis but generally includes:

• Supportive Care: Fluid replacement, anti-emetics for vomiting.
• Diagnostic Tests: Imaging studies (e.g., chest X-ray, abdominal X-ray or CT), endoscopy for GERD or gastric outlet obstruction, urine analysis for UTI, and D-dimer or CT pulmonary angiogram for pulmonary embolism.
• Specific Treatments: Antibiotics for infections, proton pump inhibitors for GERD, and specific interventions for other diagnosed conditions.
• Consultations: With specialists such as gastroenterology, neurology, or surgery, depending on the suspected underlying cause.