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Forum for Clinical and Surgical Oral Pathology
Case BBOPF 22-3
Dr. Jill White (San Francisco VA Healthcare System, San Francisco, CA. USA) is seeking you input on the following case. The case will be posted until May 9, 2022. A summary of the response will ensue shortly after.
History
75 White M h/o stage II (T3N0M0) left palatine tonsil squamous cell carcinoma s/p radiation, p16 positive SCC of the right base of tongue s/p surgical resection and chemoRT, LUL/LLL adenocarcinoma (T4N0M0) s/p IMRT (12/01/21) and durvalumab x2 c/b pneumonitis, hypoNa 2/2 SIADH, failure to thrive s/p PEG tube placement with IR on 3/31, presents with oral ulcers present since Mid-March.
Biolase was done on March 30th and biopsy of the right lateral ulcer with results:
FINAL ANATOMIC DIAGNOSIS:
TONGUE ULCER
NON-SPECIFIC ULCERATION AND INFLAMMATION (see comment)
MICROSCOPIC DESCRIPTION:
Histologic examination reveals soft tissue covered by benign-appearing
stratified squamous epithelium. There is focal area of ulceration.
Beneath the surface, acute and chronic inflammatory cells are evident
within the lamina propria and muscle.
COMMENT:
No evidence of malignancy was noted.
Negative for fungal stains, HSV and CMV immunostains negative.
Active Outpatient Medications Status
=========================================================================
1) ACETAMINOPHEN 160MG/5ML ALC-F LIQUID TAKE 4 ACTIVE
TEASPOONFULS (20 ML) ORALLY EVERY 6 HOURS AS NEEDED
FOR PAIN.
2) ACYCLOVIR 200MG/5ML ORAL SUSP TAKE 2 TEASPOONFULS (10 ACTIVE
ML) ORALLY TWICE A DAY
3) ALBUTEROL 90MCG (CFC-F) 200D ORAL INHL INHALE 2 PUFFS ACTIVE
BY MOUTH EVERY 4 HOURS AS NEEDED FOR SHORTNESS OF
BREATH
4) ALOH/DIPH/MAG/LIDO/SIMET 1:1:1 MOUTHWASH TAKE 10 ML ACTIVE
(2 TEASPOONFULS) (SWISH IN MOUTH AND SPIT OUT) FOUR
TIMES A DAY AS NEEDED FOR ORAL ULCER PAIN
5) AMOXICILLIN 400/CLAV K 57MG/5ML SUSP TAKE 2 ACTIVE
TEASPOONFULS (10 ML) ORALLY TWICE A DAY FOR
INFECTION (TAKE FOR 7 DAYS) (DISGARD REMAINING
MEDICATION AFTER 7 DAYS)
6) CHLORHEXIDINE GLUC 0.12% (AF) MOUTHWASH RINSE 15 ML ACTIVE
(1 TABLESPOONFUL - CAP FILLED TO LINE) (SWISH IN
MOUTH AND SPIT OUT) TWICE A DAY . RINSE FOR 30
SECONDS AND THEN SPIT OUT THE MEDICINE. **DO NOT
SWALLOW**
7) CLOBETASOL PROPIONATE 0.05% OINT APPLY THIN LAYER ACTIVE
TOPICALLY TWICE A DAY AS NEEDED FOR APTHOUS ULCER
IF TRIAMCINOLONE PASTE DOES NOT WORK
8) DEXAMETHASONE 0.5MG/5ML SOLN SWISH AND SPIT 1 ACTIVE
TEASPOONFUL (5 ML) ORALLY TWICE A DAY AS DIRECTED.
9) DICLOFENAC NA 1% TOP GEL APPLY 4 GRAM STRIP TOPICALLY ACTIVE
THREE TIMES A DAY AS NEEDED FOR PAIN.
10) DOXYCYCLINE HYCLATE 50MG CAP SWISH AND SPIT ONE ACTIVE
CAPSULE ORALLY TWICE A DAY AS DIRECTED. OPEN
CAPSULE AND MIX INTO ABOUT AN OUNCE OF WATER. SWISH
FOR A COUPLE MINUTES AND SPIT. LET THE TONGUE BATHE
IN SOLUTION.
11) ESOMEPRAZOLE MAG 20MG/PKT ORAL PWDR TAKE 1 PACKET (20 ACTIVE
MG) VIA FEEDING TUBE EVERY DAY . EMPTY PACKET IN 15
ML OF WATER, STIR, LEAVE 2 TO 3 MINUTES TO THICKEN;
STIR AND ADMINISTER WITHIN 30 MINUTES
12) FLUCONAZOLE 40MG/ML SUSP,ORAL TAKE 2 TEASPOONFULS (10 ACTIVE
ML) ORALLY EVERY DAY FOR 1 DAY, THEN TAKE 1
TEASPOONFUL (5 ML) EVERY DAY FOR 13 DAYS (STOP
TAKING SIMVASTATIN WHILE ON THIS MEDICATION)
(DISGARD REMAINING MEDICATION AFTER FINISHING 2
WEEKS)
13) GABAPENTIN 100MG CAP TAKE TWO CAPSULES ORALLY AT ACTIVE
BEDTIME . CAN OPEN CAPSULE AND MIX CONTENT WITH 10
ML OF WATER TO GIVE IN PUREE
14) JEVITY 1.5 CAL LIQUID TAKE 1 CARTON VIA PEG TUBE FIVE ACTIVE
TIMES A DAY AS DIRECTED
15) LEVOTHYROXINE NA (SYNTHROID) 112MCG TAB TAKE ONE ACTIVE
TABLET ORALLY EVERY MORNING BEFORE BREAKFAST FOR
THYROID.
16) LIDOCAINE HCL 2% VISCOUS LIQUID TAKE 1 TEASPOONFUL (5 ACTIVE
ML) (SWISH IN MOUTH AND SPIT OUT) FOUR TIMES A DAY
AS NEEDED FOR MOUTH PAIN
17) MELATONIN 3MG CAP/TAB TAKE TWO PILLS ORALLY AT ACTIVE
BEDTIME AS NEEDED FOR SLEEP
18) NUTRITION SUPL ENSURE PLUS/STRWBERRY LIQ TAKE 1 ACTIVE
CONTAINER ORALLY TWICE A DAY
19) NUTRITION SUPL TWOCAL HN/VANILLA LIQUID TAKE 1 ACTIVE
CONTAINER ORALLY EVERY DAY
20) NYSTATIN 100000 UNT/ML SUSP TAKE 5 ML (1 TEASPOONFUL) ACTIVE
(SWISH IN MOUTH AND SWALLOW) FOUR TIMES A DAY
21) PREDNISONE 10MG TAB TAKE THREE TABLETS ORALLY EVERY ACTIVE
DAY UNTIL 4/30/22, THEN AS DIRECTED. PLEASE FOLLOW
UP WITH YOUR DOCTOR PRIOR TO DECREASING DOSE.
22) SODIUM CHLORIDE 1GM TAB TAKE TWO TABLETS ORALLY TWICE ACTIVE
A DAY
23) SULFAMETHOXAZO 200/TRIMETH 40MG/5ML SUSP TAKE 4 ACTIVE
TEASPOONFULS (20 ML) ORALLY EVERY MONDAY, WEDNESDAY
AND FRIDAY FOR INFECTION
24) TIOTROPIUM 2.5MCG/ACTUAT 60D ORAL INHL INHALE 2 PUFFS ACTIVE
BY MOUTH EVERY DAY
25) TRIAMCINOLONE ACETONIDE 0.1% DENT PASTE APPLY PASTE ACTIVE
TOPICALLY TWICE A DAY AS NEEDED TO APTHOUS ULCER
26) ZOLPIDEM TARTRATE 5MG TAB TAKE ONE TABLET ORALLY AT ACTIVE
BEDTIME AS NEEDED FOR SLEEP
Pending Outpatient Medications Status
=========================================================================
1) LEVOTHYROXINE NA (SYNTHROID) 112MCG TAB TAKE ONE PENDING
TABLET ORALLY EVERY MORNING BEFORE BREAKFAST FOR
THYROID.
Inactive Outpatient Medications Status
=========================================================================
1) LIDOCAINE HCL 2% VISCOUS LIQUID TAKE 2 TEASPOONFULS EXPIRED
(10 ML) (SWISH IN MOUTH AND SPIT OUT) FOUR TIMES A
DAY AS NEEDED FOR ORAL ULCER PAIN
Active Non-VA Medications Status
=========================================================================
1) Non-VA CHOLECALCIFEROL *LOW* (VITAMIN D3) TAB 5000 ACTIVE
UNITS ORALLY
Request
Your differential diagnosis and management would be much appreciated.
Jill White, D.D.S., MSc. Assistant Professor
Attending Oral and Maxillofacial Pathologist
San Francisco Veterans Affairs Healthcare System
Images
March 28th
April 28th
Case prepared by Dr. Alfredo Aguirre (BBOP Manager) and Daniel Emmer (University at Buffalo School of Dental Medicine).
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