Differential Diagnosis

The patient presents with a combination of symptoms including white patches around the gums and tongue, intermittent nosebleeds, and right-sided nasal congestion. The following differential diagnoses are considered:

• Single Most Likely Diagnosis
  • Chronic Rhinitis: The patient's history of nasal congestion, especially on one side, and the improvement with Flixonase nasal spray suggest chronic rhinitis. The presence of dried blood in the nose and nosebleeds after blowing the nose further support this diagnosis.
• Other Likely Diagnoses
  • Oral Lichen Planus: The white patches on the gums and tongue could be indicative of oral lichen planus, especially given the intermittent nature and the presence of a mouth ulcer.
  • Allergic Rhinitis: The patient's history of working in a dusty environment and subsequent improvement in a cleaner environment suggests an allergic component to their rhinitis.
  • Dry Mouth (Xerostomia): The patient's symptoms of white patches and mouth ulcers could also be related to dry mouth, possibly exacerbated by their previous smoking habit.
• Do Not Miss Diagnoses
  • Nasopharyngeal Carcinoma: Although less likely, given the patient's history of nosebleeds and unilateral nasal congestion, nasopharyngeal carcinoma must be considered due to its potential severity and the need for early diagnosis.
  • Wegener's Granulomatosis (Granulomatosis with Polyangiitis): This condition can cause nosebleeds, nasal congestion, and oral ulcers, making it a critical diagnosis not to miss due to its potential for severe complications.
• Rare Diagnoses
  • Sjögren's Syndrome: An autoimmune disorder that can cause dry mouth and nasal dryness, potentially leading to the patient's symptoms.
  • Leukoplakia: A condition characterized by white patches on the mucous membranes, which can be precancerous and should be monitored closely.

Each of these diagnoses is considered based on the patient's symptoms, history, and the results of the investigations provided. The justification for each includes the matching of symptoms with known conditions, the consideration of the patient's occupational and medical history, and the process of ruling out less likely causes based on the information given.