Final Exam - Vascular & Ulcer Lesions

Question 1

39. 14 y/o male presented with unsightly pigmented spots on his lips and buccal mucosa.

Differential diagnosis for the multiple pigmented lesions?

Answer 1

• Drugs to treat lupus (anti-malarials)
• Addison’s disease
• Peutz Jegher Syndrome

Question 2

39. 14 y/o male presented with unsightly pigmented spots on his lips and buccal mucosa.

What clinical info might help in this case in establishing the diagnosis?

Answer 2

• Multiple areas with pigmented lesions
• Age (younger probably not drugs)

Question 3

40. 28 y/o white male presents with small, slightly raised pigmented lesion on left buccal mucosa. He was unaware of its presence.

Differential diagnosis?

Answer 3

• Trauma
• Hemangioma
• Varix
• Intramucosal nevus (melanocytic lesion)

Question 4

40. 28 y/o white male presents with small, slightly raised pigmented lesion on left buccal mucosa. He was unaware of its presence.

Is there any chance this lesion could have become malignant if not excised?

Answer 4

• Potentially if it is Kaposi’s or a melanoma

Question 5

41. 39 y/o white male noticed small pigmented spot on lower lip. Over 6 months lesion has increased to include almost half of the vermillion border. Lesion was flat and contained no palpable nodules.

What are the ABCD’s?

Answer 5

• Asymmetry (symmetry is a good sign)
• Borders (clear borders means benign)
• Color (uniform colors are non-malignant)
• Diameter (5-6mm is about max, beyond = malignant)

Question 6

41. 39 y/o white male noticed small pigmented spot on lower lip. Over 6 months lesion has increased to include almost half of the vermillion border. Lesion was flat and contained no palpable nodules.

Differential or Provisional diagnosis?

Answer 6

• Melanoma
• McCune Albright syndrome
• Peutz Jeghers

Question 7

41. 39 y/o white male noticed small pigmented spot on lower lip. Over 6 months lesion has increased to include almost half of the vermillion border. Lesion was flat and contained no palpable nodules.

What are the 3 major types of this disease?

Answer 7

1. Superficial spreading melanoma
2. Nodular melanoma
3. Lentigo maligna melanoma

Question 8

41. 39 y/o white male noticed small pigmented spot on lower lip. Over 6 months lesion has increased to include almost half of the vermillion border. Lesion was flat and contained no palpable nodules.

What is meant by radial growth phase and what does it show clinically?

Answer 8

• Melanoma is growing horizontally/radially in one plane of skin and can be removed.
• Stage 2 = vertical growth phase

Question 9

42. 52 y/o male thought he had melanoma from ENT exam. Presented with 1cm bluish pigmented area of his right buccal mucosa.

Provisional diagnosis?

Answer 9

Amalgam tattoo

Question 10

42. 52 y/o male thought he had melanoma from ENT exam. Presented with 1cm bluish pigmented area of his right buccal mucosa.

Is there anything you can do clinically to help establish that diagnosis?

Answer 10

Radiograph and biopsy

Question 11

43. 52 y/o male has small, slightly elevated bluish nodule on the vermillion border of his upper lip. Lesion was asymptomatic but did not know how long it’s been there.

Differential diagnosis?

Answer 11

• Hematoma
• Hemangioma
• Varix (if blanches when pushed, single varicose vein)

Question 12

43. 52 y/o male has small, slightly elevated bluish nodule on the vermillion border of his upper lip. Lesion was asymptomatic but did not know how long it’s been there.

Provisional diagnosis and what clinical procedure can be done to limit the differential diagnosis?

Answer 12

Varix - check for blanching “diascopy”

Question 13

44. 22 y/o white male presents with a sore on side of his tongue - 2cm area of ulceration. It is firm but extremely painful with palpated. Pt also has several small, tender but enlarged lymph nodes on that side.

Differential diagnosis?

Answer 13

• Traumatic ulcer
• Early ulcerative squamous cell carcinoma
• Apthous ulcer

Question 14

44. 22 y/o white male presents with a sore on side of his tongue - 2cm area of ulceration. It is firm but extremely painful with palpated. Pt also has several small, tender but enlarged lymph nodes on that side.

How would you establish a definitive diagnosis in this case?

Answer 14

• Biopsy to rule out squamous cell carcinoma
• Question patient thoroughly (frequency)

Question 15

45. 86 y/o white female complains of loose teeth. Poor oral hygiene with calculus on many teeth, inflammed and edematous tissues. Especially bad in the left mandibular cuspid-premolar area where there were also erosions and ulceration.

Differential diagnosis?

Answer 15

• Squamous cell carcinoma - (need to biopsy, any ulcer that doesn’t heal is usually a carcinoma)
• Pemphigoid
• NUG
• Fungal infection

Question 16

46. 68 y/o farmer developed ulceration on skin below left eye. Lesion was umbilicated, with a central ulcerated depression and rolled elevated borders. Lesion has been there a couple years.

Differential diagnosis?

Answer 16

**Rolled-border characteristic of BCC**

• Squamous cell carcinoma
• Keratoacanthyoma
• Basal cell carcinoma (nodular ulcerative is most common type of BCC)

Question 17

47. 22 y/o African American male cheif complaint of ulcer on his tongue. Small, slightly elevated ulcer on the mid-dorsum of his tongue, present for about a week.

Differential diagnosis?

Answer 17

• HIV-associated recurrent herpetic infection
• Squamous papilloma of the tongue
• Primary (chancre) syphilis

Question 18

47. 22 y/o African American male cheif complaint of ulcer on his tongue. Small, slightly elevated ulcer on the mid-dorsum of his tongue, present for about a week.

How would you confirm your clinical suspicion?

Answer 18

• Med Hx & social Hx
• Palpate
• Observe for changes in growth & size
• Biopsy
• Blood test

Question 19

47. 22 y/o African American male cheif complaint of ulcer on his tongue. Small, slightly elevated ulcer on the mid-dorsum of his tongue, present for about a week.

Name the 3 lesions that characterize the clinical stages of this disease?

Answer 19

1. Primary - chancre
2. Secondary - “snail track” ulcers, Condyloma lata, maculopapular cutaneous rash
3. Tertiary - gumma (large areas of necrosis), glossitis

Question 20

48. 20 y/o male presents with considerable pain because of ulceration on lateral/ventral surfaces of his tongue. Lesion started small and has slowly enlarged over a couple weeks, also has night-sweats and has lost weight.

Differential diagnosis?

Answer 20

• Chronic granulomatous disease (TB)
• Traumatic ulcer
• Ulcerative SCC

Question 21

48. 20 y/o male presents with considerable pain because of ulceration on lateral/ventral surfaces of his tongue. Lesion started small and has slowly enlarged over a couple weeks, also has night-sweats and has lost weight.

How woud you manage this case in order to arrive at a diagnosis?

Answer 21

• Biopsy

Question 22

48. 20 y/o male presents with considerable pain because of ulceration on lateral/ventral surfaces of his tongue. Lesion started small and has slowly enlarged over a couple weeks, also has night-sweats and has lost weight.

What is meant by granulomatous inflammation?

Answer 22

• Mass effect, night sweats due to pulmonary TB
• Causes necrotizing granulomas (acid-fast stain)

Question 23

49. 43 y/o white female developed “blisters” of her hard palate over last couple days. She now has multiple small ulcers of her hard palate.

Provisional diagnosis?

Answer 23

• Recurrent inra-oral herpes
  
  • mostly occurs on attached gingiva and palate

Question 24

50. 4th year dental student developed a small cluster of vesicles on the vermillion border of his lower lip. Night before said that it itched.

Provisional diagnosis?

Answer 24

• Herpes labialis

Question 25

50. 4th year dental student developed a small cluster of vesicles on the vermillion border of his lower lip. Night before said that it itched.

You have a cut on your finger, what precautions should you take in examining this patient?

Answer 25

• Wear gloves!
• Don’t perform any treatment

Question 26

50. 4th year dental student developed a small cluster of vesicles on the vermillion border of his lower lip. Night before said that it itched.

What are the treatment options?

Answer 26

• Goes away on its own, anti-virals topicals can be used
• Acyclovir (topical)
• Valtrex (systemic)

Question 27

51. 25 y/o white female presents complaining of pain in her left cheek. 1cm ulceration of posterior buccal mucosa. The ulcer had a white surface and was surrounded by an erythematous border. Lesion has been present for 4 days.

Differential diagnosis, provisional too?

Answer 27

• Acute reactive ulcer (stomatitis)
• Aphthous ulcer (recurrent)
• Primary herpetic gingivotomatitis

Question 28

51. 25 y/o white female presents complaining of pain in her left cheek. 1cm ulceration of posterior buccal mucosa. The ulcer had a white surface and was surrounded by an erythematous border. Lesion has been present for 4 days.

What is the currently accepted pathogenesis for this condition?

Answer 28

• Stress, trauma, lack of vitamin (especially B12)
• Immune pathogenesis, TNF alpha

Question 29

51. 25 y/o white female presents complaining of pain in her left cheek. 1cm ulceration of posterior buccal mucosa. The ulcer had a white surface and was surrounded by an erythematous border. Lesion has been present for 4 days.

What are the treatment options?

Answer 29

• Should resolve itself in 7-10 days
• Can treat with corticosteroids to alleviate pain
• Fluosinomide - must start at prodromal phase