Differential Diagnosis
The patient's symptoms of fever, low blood pressure, tachypnea, significant right upper quadrant tenderness with guarding, confusion, and scleral icterus suggest a severe and potentially life-threatening condition. The differential diagnosis can be categorized as follows:
- Single most likely diagnosis + Acute cholecystitis with sepsis: This condition is likely given the combination of right upper quadrant tenderness, fever, and systemic signs of infection such as low blood pressure and confusion. The presence of scleral icterus may indicate associated liver dysfunction or bile duct obstruction.
- Other Likely diagnoses + Cholangitis: Inflammation of the bile duct, often due to obstruction, which can present with similar symptoms including fever, jaundice (suggested by scleral icterus), and abdominal pain. The presence of confusion and low blood pressure suggests a severe infection. + Liver abscess: A collection of pus in the liver, which can cause fever, right upper quadrant pain, and systemic symptoms. While less common, it is a plausible diagnosis given the patient's presentation. + Pyogenic liver abscess with sepsis: Similar to a liver abscess but with a systemic infection component, which could explain the low blood pressure, tachypnea, and confusion.
- Do Not Miss (ddxs that may not be likely, but would be deadly if missed.) + Ruptured liver cyst or tumor: Although less common, a rupture could lead to severe abdominal pain, hemorrhage, and shock, presenting with some of the patient's symptoms. + Hemorrhagic pancreatitis: While the primary pain location for pancreatitis is usually epigastric, it can radiate and cause significant systemic symptoms, including shock and confusion, especially if there is a hemorrhagic component. + Septic shock from another source (e.g., pneumonia, urinary tract infection): The patient's symptoms of fever, low blood pressure, and confusion could be indicative of septic shock from a source other than the abdomen, which would require immediate identification and treatment.
- Rare diagnoses + Amebic liver abscess: Caused by Entamoeba histolytica, this condition can present with right upper quadrant pain and systemic symptoms but is less common in areas where the parasite is not endemic. + Echinococcal cyst rupture: A parasitic infection that can cause cysts in the liver, rupture of which can lead to anaphylactic shock, severe abdominal pain, and other systemic symptoms, although this is relatively rare and usually seen in specific geographic locations.