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Clinical Competency

A 48-year-old male patient presents with a 1.0 cm white plaque on the right lateral border of the tongue, associated with induration and an epithelialized depression. His medical history includes 20 years of tobacco use (½ pack/day, quit 1 month ago) and previous alcohol dependence. Current medication is Lisinopril for hypertension. A provisional diagnosis of leukoplakia was made due to lack of trauma history, with differential diagnosis including hyperkeratosis and squamous cell carcinoma (SCC). A biopsy is planned at the 6-week follow-up if the lesion persists.

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Clinical Competency

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  1. Clinical Competency Brian Hollabaugh Case # 546-9-04

  2. Patient History • Medical History • HTN • Previous 20yr. tobacco use, ½ pack a day, quit 1 mo. ago • Previous alcohol dependence • Medications • Lisinopril unknown amount 1/day for HTN • Allergy • NKDA

  3. Lesion Description • 48 M with elongated 1.0 cm white plaque of right lateral border of tongue with history of risk factors, assosiated with indurationanteriorly with no history of trauma, and sharply punched out 0.3 cm epithelialized depression of unknown duration.

  4. Patient Dialogue • Have you noticed this lesion on the side of your tongue? (No) • Does this area of your tongue rub on your teeth? (Not aware) • Has your previous dentist mentioned this lesion? (No) • How long ago did you quit drinking? (A few years ago) • Did you drink and smoke during the same time period? (Yes) • Is your tongue ever painful? (No) • Have you recently bitten down on your tongue? (Not aware)

  5. Diagnosis • Differential Diagnosis • Hyperkeratosis • Leukoplakia • SCC • Provisional Diagnosis • Leukplakia • This diagnosis is made due to not having a history of trauma to the area ruling out hyperkeratosis . As well as not having a biopsy at this point and therefore SCC couldn’t be diagnosed. A biopsy will be done when the pt. returns at 6 weeks if lesion still persists.

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