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Patient History and Physical Exam: HPI:  This is a 65-year-o…

Patient History and Physical Exam: HPI:  This is a 65-year-old male patient who presents with a complaint of a “possible left foot infection”. Pt reports this started about 3 months ago. The affected area is located and isolated to the top of the left second toe and has gotten bigger since it started. Pt reports he sought care at an urgent care where they prescribed him an antibiotic a month ago and this got “a little bit better, but not much”. He was instructed to follow up with his primary care provider, prompting his visit today. Unfortunately, since that visit, the pt reports his symptoms have worsened and never fully went away. Pt states that the area is painful, achy, and has started to turn dark and red in places. He describes the pain as “achy” and “burning”, rating it 5/10 currently. The pain never seems to fully go away and is worse with walking or prolonged standing. He notes the pain is somewhat better elevation of the foot. Elevation seems to help improve the pain. The pain radiates up and down the leg at times. Pt does not recall any specific preceding trauma or cold exposure prior to the onset of this. He reports he thinks he has an infection because there appears to be a wound on the foot that has been present since his symptoms started, 3 months ago. This has been consistently present, only slightly improved after taking antibiotics.   As for associated symptoms, the pt also reports intermittent pains in both legs at times, particularly after doing a lot of walking but admits to doing less walking lately because of this. The pains run up and down the lower legs below the knee without other radiation.  Additionally, he states that the left leg sometimes feels cool to the touch compared to the right leg. With that, he notes tingling at times in the left leg. No complete loss of sensation reported. No other wounds or skin problems of the legs reported elsewhere. Pt admits to slow healing of scratches on his legs in the past, but nothing like this. Pt denies recent fall/injury or known preceding trauma.    Medications: Lisinopril/HCTZ 20/25mg PO daily Carvedilol CR 20 mg PO daily Atorvastatin 40mg, one tablet taken PO at bedtime Tamsulosin 0.4mg, one tablet taken PO daily Daily multivitamin (generic, OTC) – one tablet taken PO daily at breakfast Tylenol 650mg PO 1-2 times daily on occasion for B/L leg pain Allergies: Morphine (causes itching) Past Medical History: Chronic conditions:  Primary Hypertension (diagnosed 25 years ago) Hyperlipidemia (diagnosed 20 years ago) BPH (diagnosed 10 years ago) Surgeries:  Right Achilles tendon rupture s/p repair 2014 Left radius fracture s/p repair ORIF 2019 Health Maintenance/Immunizations: Up-to-date on most recommended, age-appropriate vaccines including COVID, influenza, Tdap. He has not had a shingles or a pneumonia vaccine. Pt last colonoscopy was 15 years ago at age 50 (no concerning findings reported). Family History: Father: Deceased, age 61 due to heart attack. PMHx included HTN and COPD (he was reported to be a smoker) Mother: Alive, age 75, PMHx includes HTN, high cholesterol Siblings (2):      Brother – age 52, alive, PMHx includes: heart attack and high cholesterol  Sister – deceased at age 56 due to heart attack Children (3) are all reported to be alive and well.  Ages 25 (F), 23 (F), and 20 (M) Social History:  Tobacco/Vape: Pt reports 1 PPD use of cigarettes for the last 30 years) Alcohol: Pt reports having an occasional beer 2-3 times per week. Illicit drugs: Pt denies illicit or prescription drug use/abuse currently or recently. Pt admits to prior marijuana use in his 20’s, but none since.  Marital/Sexual: Divorced once at age 23, then has been re-married for the last 28 years with three children.  Living situation: Lives in a home with his wife in El Centro  Job: Recently retired Executive Accounts Manager for the City of San Diego (he worked at this job for 35 years) Hobbies: Spending time with his family, fishing, and growing vegetables in his garden to share with family and friends. Diet: No specific diet followed, normal American diet. Pt states he enjoys eating BBQ at cookouts with his friends Religion: Catholic Sleep: Averages 6-7 hours of sleep per night ROS: General: No more fatigue than usual, but less active than usual due to leg pains  No recent weight changes (up or down) No fever/chills or appetite changes Skin: See HPI. +Pt has left foot second toe wound with reported overlying skin changes and discoloration (reported as “dark and red in certain place”). The area is not reported to be hot to the touch.  No diaphoresis, jaundice. Head, Eyes, Ears, Nose, Throat (HEENT): No vision changes, no redness, no itching, no tearing, no discharge No ear pain, tinnitus, hearing changes No nasal congestion, sinus pain/pressure No gum bleeding No facial swelling, jaw pain, sore throat, or difficulty swallowing No neck pain, or LAD Respiratory: No SOB, DOE, PND or orthopnea No cough or recent URI symptoms No pain with breathing No hemoptysis Cardiovascular: No chest pain, palpitations No generalized LE edema No syncope or light-headedness  Gastrointestinal: No abd pain, distension, or n/v No diarrhea/constipation, no blood in stool or melena Genitourinary: No changes in, or difficulty with, urinating.  No polyuria, no nocturia, no hematuria, no flank pain Musculoskeletal: +See HPI. +Left foot pain, particularly at the 2nd toe. The pain waxes and wanes depending on activity. L 2nd toe wound reported. +B/L distal leg pain at times, waxes and wanes. No new weakness or joint pain Neurological: See HPI. +Paresthesias to L foot at times.  No numbness, focal weakness. No HA, dizziness, vertigo, or tremor. No confusion Psychiatric: No unusual changes in mood, racing thoughts, grandiose ideas, or paranoia No insomnia or recent lack of sleep No suicidal ideations, auditory or visual hallucinations Endocrine: No heat or cold intolerance, no polyuria or polydipsia Hematologic/Lymphatic: No easy bruising or bleeding, no epistaxis Physical Exam Findings:  VITAL SIGNS:  Temperature: 36.8°C (98.2°F) Pulse rate: 89 bpm Respiration Rate: 19/min Blood pressure: 145/85 mmHg Oxygen saturation: 97% on room air Weight: 75 kg (160 lb) Height: 182 cm (72 in) GEN: Well-developed, well-nourished male. Afebrile. Appears in no general distress. Alert and oriented x 4, answering questions appropriately. HEENT NCAT, normal conjunctiva and sclera color B/L. PERRLA B/L. EOMI B/L. Fundoscopic exam revealed AV nicking, arteriolar constriction, cotton-wool spots, and yellow hard exudates B/L. Visual fields appear grossly intact B/L. Mucous membranes without dryness or pale coloration. No oral swelling. Oropharynx clear. NECK: No appreciable JVD noted. NML c-spine ROM. No palpable neck mass or LAD. SKIN: See attached photo (below) of pt’s L foot/toes. Skin is warm, dry. B/L LE with thin-appearing, tight skin to distal LEs above the ankles B/L. There is a 0.5 inch round area of ulceration and dark discoloration overlying the dorsal aspect of the 2nd toe. There is mild swelling associated. There is some ecchymoses / purple discoloring to the distal aspect of the 2nd toe beyond the wound. There is some skin flaking surrounding the area, with subtle erythema extending toward the dorsal aspect of the midfoot. No diaphoresis. Left foot:   HEART/CHEST: Heart sounds with regular rate and rhythm with S1/S2 heard with notable S4 gallop. Displaced PMI just lateral to MCL and to approx. 6/7th intercostal space. No M/R/G. Chest appears hyperinflated and hyper-resonant B/L.  LUNGS: Clear to auscultation B/L with prolonged expiratory phase. No noted increased respiratory effort such as sternal retractions. No wheezing or stridor. PERIPHERAL VASCULAR: No LE edema noted. UE pulses: brachial 2+ B/L, 2+ radial B/L. LE’s pulses as follows: Femoral 2+ B/L, PT 1+ B/L, DP trace on L, 1+ on R. Capillary refill UE’s was

Section Task 3: (A.) Based on the provided historical and ph…

Section Task 3: (A.) Based on the provided historical and physical exam information up to this point, please review and update your differential diagnosis list as you see fit. You may add/change diagnoses as necessarily to update this list. After your review, please list your updated top three (3) most likely diagnoses. Your number 1 (top) diagnosis should be the diagnosis you feel is most likely in this case. [PLO 2] (B.)  Then, please select and list a total of three (3) diagnostic tests that will be useful in establishing your suspected diagnoses. These may include laboratory tests, imaging, and/or diagnostic procedures. [PLO 3] (C.) Explain your reasoning for each test.  Include the medical condition for which you are testing and your expected test result for that condition.   

Patient History and Physical Exam: HPI:  Agatha Dubois is a…

Patient History and Physical Exam: HPI:  Agatha Dubois is a 65-year-old female patient who presents with a complaint of noticing blood in the toilet after she urinated a few days ago. Pt reports this episode occurred once 3 days ago and has not returned since. She reports the toilet water was tinged red when she got up. She reports that she had two prior similar episodes 6-7 months ago and sought care online via a telehealth platform through her job. She reports she was diagnosed with a “UTI” and was treated with an antibiotic (cannot recall which one), and states no testing was actually done to assess her. She reports no recurrence of the blood since that time, until 3 days ago, so she hadn’t worried about it until now.  Pt admits to increased nocturia, with a sense of urinary urgency at times during the day. She reports no dysuria, flank pain, decreased urine output, incontinence, or abdominal pain associated with this and is unsure when the blood shows up (i.e., cannot distinguish if it is the entire stream, versus start or end). She reports no fever, night sweats, or chills. When specifically asked, the pt could not be entirely sure that the blood was in her urine versus vaginal bleeding that ended up in the toilet. She feels generally confident that it came from urination, however.  Pt reports no symptoms prior to this occurring 6-7 months ago. Pt denies other associated symptoms and denies preceding trauma, exercise prior onset, injury, or recent fall. No recent or remote international travel. She denies easy bruising or bleeding otherwise. No constipation, straining at stool, melena, or blood in stool reported. She denies eating beets, red food coloring, or other red-colored food items. Medications: Metoprolol Succinate (ER) 50mg PO daily HCTZ 25mg PO daily Atorvastatin 40mg PO QHS No over-the-counter medications taken at this time Allergies: Sulfa Drugs (causes lip swelling and rash) Past Medical History: Chronic conditions:  Primary Hypertension (diagnosed 20 years ago) Hyperlipidemia (diagnosed 20 years ago) No known bleeding disorder or hx of abnormal bleeding Surgeries:  Benign thyroid nodule removal (age 55)  R wrist fracture ORIF repair (age 42) due to a fall Health Maintenance/Immunizations:  Up-to-date on most recommended, age-appropriate vaccines including COVID, influenza, Tdap. Pt reports she has not had a shingles or a pneumonia vaccine when asked.  Pt’s last colonoscopy was 15 years ago at age 50 (no concerning findings reported). Pt has not yet completed any osteoporosis screening OB-GYN:  G2P2002. Both spontaneous vaginal births with minimal complications of note.  Pt completed routine pap smears/exams until age 60, at which time pt discontinued seeking women’s health care. She reports having an abnormal pap smear at age 50, but negative HPV testing throughout the years. She states the abnormality required “watching only”.   Family History: Father: alive, 89 years old. Known hx of hypertension, hyperlipidemia, dementia. Mother: alive, 88 years old. Known hx of obesity, melanoma skin cancer (s/p Mohs surgery for removal), HTN, and diabetes type 2. Sister 1: alive, age 62, history of Type 2 DM, obesity, high cholesterol Sister 2: alive, age 64, history of thyroid cancer s/p thyroidectomy, chronic back pain Children: two, both alive and well Child 1 (female): Age 30, healthy Child 2 (male): Age 32, healthy   Social History:  Tobacco/Vape: Hx of tobacco use (age 20-50, has quit since age 50, reports smoking half pack to full pack per day during those years; with an estimated 22.5 pack/year hx) Alcohol: An occasional glass of wine on weekends Illicit drugs: Denies drug use  Marital/Sexual: Pt is widowed (husband died 6 years ago from colon cancer), recently started dating again and has a new male partner as of 3 months ago. She is sexually active with that person and reports no use of contraceptive or birth control. Living situation: Lives in a condo in Santee Job: Retired nurse Hobbies: Golf, learning to sew/crochet, and loves photography Diet: Normal, no current restrictions or dietary allergies Religion: Atheist Sleep: Averages 6-7 hours of sleep per night ROS: Constitutional: See HPI. No changes in appetite. No reported unexplained weight loss or gain recently.  Skin: Denies hair changes, nail changes, rash, lesions, bruising, or skin discoloration.  HEENT: Denies rhinitis, sore throat, congestion, ear pain or discharge, eye pain or change in vision, or headache. Denies hearing loss, tinnitus, or nasal discharge. No lymph node or gland swelling reported. CV/PV: No chest pain, palpitations, swelling, cyanosis, or edema of extremities. No syncope reported.  Pulmonary:  No cough, SOB, dyspnea, orthopnea, or PND.  GI:  See HPI. Denies constipation, diarrhea, fecal incontinence, abdominal distention, or heartburn. No blood in stool reported or dark/tarry stools. GU:  See HPI. Denies urinary incontinence, dysuria, or flank pain. MSK:  Denies muscle aches/pain, joint swelling, or joint discoloration. No changes in gait. No back pain, neck pain, or joint pain. Neuro: Denies headaches, dizziness or lightheadedness, speech changes, slurred speech, numbness or weakness anywhere. Denies seizures, tremors, or confusion.  Psych: Denies depression, mania, suicidal ideation, homicidal ideation or hallucinations. Endocrine: Denies heat or cold intolerance, polydipsia, or polyphagia.  Heme/Lymph: Denies easy bruising or gum bleeding. Physical Exam Findings:  VITAL SIGNS:  Temperature: 37.2°C (98.9°F) Pulse rate: 80 bpm Respiration Rate: 18/min Blood pressure: 126/80 mmHg. Oxygen saturation: 99% on room air Weight: 79.5 kg (175 lb) Height: 182 cm (72 in) GEN: Well-developed, well-nourished female. Appears in no acute or general distress. Alert and oriented x 4, answering questions appropriately.  HEENT Atraumatic, normocephalic. Ear canals clear bilaterally, TMs pearly gray with no bulging or defect noted. Nares patent, septum intact. Lips and gingiva normal in appearance, posterior pharynx without erythema or exudates. PERRLA, EOMI B/L. NECK: Neck is supple, no masses, trachea midline, no thyroid nodules, masses. No lymph node tenderness or enlargement.  SKIN: No bruising, cyanosis, or pigment changes appreciated, without obvious lesions or rashes. Normal hair pattern. HEART: Regular rate, regular rhythm with normal S1, S2, without rubs, murmurs or gallops auscultated. No peripheral edema noted. No JVD. LUNGS: Clear to auscultation B/L. No adventitious breath sounds. No increased respiratory effort appreciated. No wheezing, rales, rhonchi, or stridor. PERIPHERAL VASCULAR: Capillary refill WNL throughout extremities, < 2s. No peripheral edema. Pulses 2+ and intact at DP, PT, brachial and radial B/L. No digital clubbing noted. ABD: Normoactive bowel sounds heard throughout all quadrants. Soft, non-distended abdomen without tenderness to light or deep palpation. No rebound or guarding noted. No hepatosplenomegaly noted. No abdominal bruits or pulsatile masses. No CVA tenderness elicited B/L. The bladder does not feel distended on palpation. No masses appreciated on deep palpation. GU/Rectal:  Pelvic exam reveals pink, multiparous, non-friable cervix. No discharge, CMT, or bleeding from closed cervical os. No appreciable mass or deformity. Vaginal canal without blood present throughout. No inguinal LAD appreciated.  Rectal exam reveals normal sphincter tone. No hemorrhoid, mass, or lesions noted externally. Hemoccult testing negative. NEURO: Pt alert and oriented x 4, following commands appropriately. Speech clear and without slurring. No facial asymmetry. Gait steady and without limp or need for assistance. Strength 5/5 in all extremities and major muscle groups, equally throughout B/L sides. No sensory deficit appreciated throughout extremities.  PSYCH: Affect and mood normal. Judgment and insight intact; no confusion. No homicidal or suicidal ideation. No pressured or tangential speech. No evidence of hallucinations.   Section Task 3: (A.) Based on the provided historical and physical exam information up to this point, please review and update your differential diagnosis list as you see fit. You may add/change diagnoses as necessarily to update this list. After your review, please list your updated top three (3) most likely diagnoses. Your number 1 (top) diagnosis should be the diagnosis you feel is most likely in this case. [PLO 2] (B.)  Then, please select and list a total of three (3) diagnostic tests that will be useful in establishing your suspected diagnoses. These may include laboratory tests, imaging, and/or diagnostic procedures. [PLO 3] (C.) Explain your reasoning for each test.  Include the medical condition for which you are testing and your expected test result for that condition. 

Consider the argument from contingency offered by Aquinas:  …

Consider the argument from contingency offered by Aquinas:            (1.) If everything existed contingently, then every object would fail to exist at some time.            (2.) If everything failed to exist at some time, then there would be a time when nothing exists.            (3.) If there were a time when nothing exists, then the universe would be empty.            (4.)  The universe is not empty.             Therefore, not everything exists contingently, i.e. there is a necessary being. Which of the four premises involves the birthday fallacy?