What is the diagnosis and management for a 43-year-old patient with a past medical history (PMH) of hypertension (HTN), diabetes mellitus (DM), anxiety, depression, obesity, and alcohol abuse, presenting with a chronic cough, left heel pain, and a white tongue lesion, with a history of recent hospitalization for chest consolidation and elevated blood pressure (BP)?

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Differential Diagnosis

  • Single most likely diagnosis
    • Chronic bronchitis: Given the patient's history of smoking and ongoing cough for 1 month, chronic bronchitis is a likely diagnosis. The patient's reduction in smoking to 1-2 cigarettes/day may not be sufficient to alleviate symptoms immediately.
    • Plantar fasciitis: The left heel pain coinciding with new shoes and pain on stepping suggests plantar fasciitis, a common condition in individuals with new or poorly fitting shoes.
    • Oral thrush: The painless white spot on the tongue tip for 6 months could be oral thrush, especially given the patient's history of diabetes and possible immunocompromised state.
  • Other Likely diagnoses
    • Pneumonia: Although the patient had a hospitalization 6 months ago involving chest consolidation, the ongoing cough could still be related to a respiratory infection such as pneumonia.
    • Heel spur: The left heel pain could also be due to a heel spur, which is often associated with plantar fasciitis.
    • Lichen planus: The white spot on the tongue could be lichen planus, an inflammatory condition that can cause white patches on the mucous membranes.
    • Hypertension exacerbation: The patient reports elevated BP today, which could be related to their history of hypertension, and may require adjustment of their medication regimen.
  • Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
    • Lung cancer: Given the patient's history of smoking, lung cancer is a possibility that should not be missed, despite the patient's reduction in smoking.
    • Tuberculosis: The patient's history of hospitalization with chest consolidation and ID consult raises the possibility of tuberculosis, which can present with cough and chest symptoms.
    • Endocarditis: The patient's history of ID consult and hospitalization raises the possibility of endocarditis, which can present with systemic symptoms such as fever and fatigue.
    • Diabetic foot infection: The patient's history of diabetes and left heel pain raises the possibility of a diabetic foot infection, which can be serious and require prompt treatment.
  • Rare diagnoses
    • Sarcoidosis: The patient's history of cough and chest consolidation could be related to sarcoidosis, a rare condition that can cause granulomatous inflammation in the lungs.
    • Histoplasmosis: The patient's history of hospitalization with chest consolidation and ID consult raises the possibility of histoplasmosis, a rare fungal infection that can cause respiratory symptoms.
    • Oral cancer: The white spot on the tongue could be oral cancer, although this is less likely given the patient's description of the lesion as painless.

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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