Please write a SOAP note for a 54‑year‑old female presenting with painful oral ulcerations and tongue swelling.

SOAP Note: 54-Year-Old Female with Mouth Sores and Tongue Swelling

SUBJECTIVE

Chief Complaint: Mouth sores and tongue swelling

History of Present Illness:

• Duration of symptoms (critical: note if >2 weeks, which triggers different diagnostic pathway 1)
• Pain level and character
• Frequency: first episode vs. recurrent (recurs every few months suggests recurrent aphthous ulcers)
• Recent trauma, dental work, or new medications
• Response to any prior treatments (failure to respond after 1-2 weeks necessitates biopsy 1)
• Constitutional symptoms: fever, weight loss, fatigue, joint pain
• Skin lesions, genital ulcers, or eye symptoms (suggests systemic disease 2)

Past Medical History:

• Autoimmune diseases (lupus, inflammatory bowel disease, Behçet's)
• Diabetes (predisposes to fungal infections 1)
• HIV status or risk factors
• History of sexually transmitted infections
• Blood disorders or anemia
• Previous similar episodes

Medications & Allergies:

• Current medications (some cause oral ulceration)
• Recent antibiotic use
• Over-the-counter products applied to mouth
• Known drug allergies

Social History:

• Smoking/tobacco use
• Alcohol consumption
• Sexual history (syphilis consideration 3)
• Stress levels (associated with recurrent aphthous ulcers 1)

OBJECTIVE

Vital Signs: Temperature, blood pressure, heart rate, respiratory rate

Oral Examination - Document Precisely:

Ulcer Characteristics:

• Location: Buccal mucosa, tongue (lateral/dorsal/ventral), gingiva, palate, floor of mouth
• Number: Solitary vs. multiple
• Size: Measure in millimeters
• Shape: Round/oval (suggests recurrent aphthous ulcers 1) vs. irregular (concerning for malignancy) vs. stellate (tuberculosis 1)
• Borders: Well-demarcated vs. irregular/rolled edges (malignancy concern)
• Base: White/yellow pseudomembrane with erythematous halo (classic for recurrent aphthous ulcers 1) vs. indurated vs. necrotic
• Depth: Superficial vs. deep with undermined edges (tuberculosis 1)
• Palpation: Soft vs. indurated (induration suggests malignancy)

Tongue Swelling:

• Diffuse vs. localized
• Symmetry
• Color changes
• Associated ulceration

Adjacent Structures:

• Sharp tooth edges, broken restorations, or ill-fitting dentures (traumatic cause 1)
• Gingival health
• Lymphadenopathy: cervical, submandibular, submental nodes (size, consistency, mobility, tenderness)

Extraoral Examination:

• Skin lesions (pemphigus, pemphigoid, lichen planus, erythema multiforme 4)
• Eye examination if indicated
• Genital examination if systemic disease suspected

ASSESSMENT

Differential Diagnosis (Prioritized by Likelihood and Severity):

1. Recurrent Aphthous Ulcers (most common if recurrent, well-demarcated, round/oval with pseudomembrane 1)

2. Traumatic Ulceration (if location corresponds to sharp tooth/restoration 1)

3. Infectious Causes:

   • Herpes simplex (if vesicles present, typically labial/anterior oral cavity 4)
   • Syphilis (progressive ulcer, consider with any unexplained oral ulcer 3)
   • Fungal infection (especially if diabetic 1)
   • Tuberculosis (stellate ulcer with undermined edges 1)

4. Autoimmune/Immunobullous Diseases:

   • Pemphigus vulgaris
   • Mucous membrane pemphigoid
   • Erosive lichen planus
   • Behçet's disease

5. Malignancy (squamous cell carcinoma - MUST rule out if solitary, indurated, >2 weeks duration 2)

6. Systemic Disease-Associated:

   • Inflammatory bowel disease
   • Nutritional deficiency (iron, folate, B12)
   • Blood dyscrasias

PLAN

Immediate Actions:

1. Laboratory Testing (Order BEFORE biopsy if indicated 1):

Essential baseline labs:

• Complete blood count with differential (rule out anemia, leukemia 1)
• Coagulation studies (PT/INR, PTT - biopsy contraindication screening 1)
• Fasting blood glucose (biopsy contraindication; fungal infection risk 1)
• HIV antibody 1
• Syphilis serology (RPR/VDRL and treponemal test 1)

If anemia suspected on CBC:

• Serum iron, ferritin
• Folate level
• Vitamin B12 level
• Consider bone marrow biopsy if hematologic malignancy suspected 1

If autoimmune bullous disease suspected clinically:

• Anti-Dsg1, anti-Dsg3 antibodies (pemphigus)
• Anti-BP180, anti-BP230 antibodies (bullous pemphigoid) 1

2. Biopsy Indications - MUST PERFORM IF 1:

• Duration >2 weeks
• No response to 1-2 weeks of empiric treatment
• Solitary ulcer with concerning features (induration, irregular borders)
• Atypical presentation
• Cannot establish clinical diagnosis

Biopsy technique:

• Include ulcer edge and adjacent normal tissue
• Submit for routine histopathology (H&E staining)
• If bullous disease suspected: Submit separate specimen for direct immunofluorescence (DIF) 1
• Consider fungal/bacterial culture if infectious etiology suspected

3. Empiric Treatment (While Awaiting Results):

For suspected recurrent aphthous ulcers (if typical appearance, recurrent history, no red flags):

• Topical corticosteroids: triamcinolone acetonide 0.1% in orabase, apply 2-4 times daily
• Chlorhexidine gluconate 0.12% mouth rinse twice daily
• Pain management: viscous lidocaine 2% or benzocaine gel as needed
• Avoid irritating foods (spicy, acidic, rough textures)

If traumatic cause identified:

• Remove/smooth sharp edges of teeth or restorations
• Dental referral if needed
• Lesion should resolve within 7-10 days after removing irritant

4. Referrals:

• Oral medicine specialist or oral surgeon: For biopsy if indicated
• Dentist: If dental trauma identified
• Dermatology: If skin lesions present or suspected immunobullous disease
• Infectious disease: If HIV positive or complicated infection

5. Patient Education:

• Avoid tobacco and alcohol (delay healing, increase malignancy risk)
• Maintain good oral hygiene
• Document lesion with photos if possible for monitoring
• Return immediately if: difficulty swallowing/breathing, fever, rapid progression, bleeding

6. Follow-Up:

• 2 weeks: Re-evaluate if empiric treatment initiated
• Sooner if biopsy performed: Review pathology results
• If no improvement at 2 weeks: Proceed to biopsy if not already done 1

Critical Red Flags Requiring Urgent Workup:

• Solitary ulcer >2 weeks duration (malignancy until proven otherwise)
• Indurated or fixed lesion
• Rapid progression
• Constitutional symptoms (fever, weight loss)
• Airway compromise from tongue swelling

The key principle: oral ulceration lasting >2 weeks or failing 1-2 weeks of treatment mandates biopsy to exclude malignancy and establish definitive diagnosis 1. Blood work must precede biopsy both to screen for contraindications and to provide diagnostic clues for systemic disease 1.