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Clinical Competency

Clinical Competency. Brian Hollabaugh Case # 546-9-04. 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. Lesion Description.

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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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