Primary Presentation
of Simulated
Oral Medicine Case
Name: Mohammed AL-Qarni
Computer number: 1760972
Serial number: #82
Name: Rakan AL Harbi
Computer number: 1742376
Serial number: #61
A 50-year-old male patient with a history of liver transplant
completed 1 year ago (currently on Rapamune 2g/day) presented to
the dental clinic. He has hypertension (currently on propranolol). He
has been a social cigarette smoker for the past 15 years. He has no
recent dental work done.
The patient came complaining from a sore tongue that has started 3
weeks ago and has been getting worse. He has been prescribed
antibiotics and nystatin by other providers without any benefit. He
has been on chlorhexidine continuously without any benefit. He is not
able to tolerate acidic and spicy food. Often, he has to take ibuprofen
to control his mouth pain. No similar history has been reported
before.
Biographic Data
• Age: 50-year-old
• Gender: Male
Chief Complaint
• sore tongue that is exacerbated by acidic and
spicy foods
History of Chief Complaint
• Onset: started 3 weeks ago
• Location: lateral border of the tongue
• Duration: not mentioned in the case.
• Character: not mentioned in the case.
• Aggravating factors: acidic and spicy food.
• Relieving factors: ibuprofen to control his
mouth pain
Medical History
• Medical history
patient with a history of liver transplant
completed 1 year ago .
hypertension.
Medications
• - currently on Rapamune 2g/day.
• - currently on propranolol.
Family History
• Not mentioned.
Social History
Marital status: Not mentioned.
Number of children: Not mentioned.
Occupation: Not mentioned.
Habits: He has been a social cigarette smoker
for the past 15 years.
Oral habits: Not mentioned.
Dental History
• Dental history: He has no recent dental work
done.
• Oral hygiene habits and frequency: Not
mentioned.
Clinical Examination
Extraoral Findings
Not mentiond.
Vital Signs
• Not mentiond.
Clinical Examination
Intraoral Findings
Documentation of abnormal findings by given
photographs.
Lesion Description
 Single Well defined
yellowish Ulcerative
acute lesion with
indurated borders on
the left lateral border
of the tongue which is
approximately 2-3 cm
in length.
Differential Diagnosis
I. Recurrent Aphthous Stomatitis
II. squamous cell carcinoma
III. Eosinophilic Ulcer of Tongue (TUGSE)
Working Diagnosis
Recurrent Aphthous Stomatitis
Case Management in First Visit
•
•
•
Non-pharmacologic management:
 History details: asking about family history: if the patient has previously had the ulcer and how many times has
it appeared in the past.
Also asking about oral hygiene habits and past dental history.
also asking about oral habits
 Patient education: instructing the patient to chew on the other side and avoid irritating factors in addition to spicy
and acidic foods while using the medicine on the lesion
Diagnostic aids:
 Biopsy to know whether there is the possibility of malignancy
 Laboratory investigation(s) to eliminate the possibility of viral infection
 Radiographic imaging to see possible signs of malignancy
Pharmacologic management: betamethasone 0.1% cream of 0.05% gel bid (TP) (TID) for 1 week
15/10/2020
Dr. hani mwardi
500 Broadway Malden, MA
Malden, MA 02148, USA
Re: ahmed
Dear dr. Hani