Question: chief complaint history of present illness a 52 yo female...
History of Present Illness
A 52 y.o. female presents with the chief complaint that her tongue is red x 2 weeks. Her dental hygienist mentioned it to her at a recent apt and told her to get it “checked out.” States she has noticed a change in taste when she eats spicy foods. She reports that she noticed the change in taste when she started using a new brand of toothpaste one month ago.
Past Medical History/Current Meds
Self-diagnosed acid reflux treated with OTC omeprazole PRN
Hiatal hernia surgery 3 years prior
Drinks 2-3 glasses of wine per week. Denies tobacco use or drug use.
Review of Symptoms
As noted per HPI only, not completed
Vital signs: HR 103, BP 128/71, HT 68 inches, WT 130 lbs.
General: Well appearing
EENT: eyes anicteric, PERRL, TM’s pearly gray, mucous membranes are moist. Tongue is slightly enlarged, smooth with a reddish appearance. Mildy tender to palpation. 1.5 cm fissure present. No ulcerations present.
Neck: Supple, no lymphadenopathy noted
CV: S1/S2 present, regular rhythm. No murmurs, clicks or rubs.
Respiratory: Clear to auscultation bilaterally
MSK: FROM, strength 2+, coordinated. No lesions, deformities.
Case Study Discussion – Part I:
Identify a minimum of three conditions that you would consider in your differential diagnosis, with the most likely condition listed first. Provide rationale for each differential with supporting evidence from the case study.
What further history, further examination, and diagnostic studies should be considered in order to explore your differential diagnosis and confirm your suspicions?