A 34 year old male presents with general malaise which has been worsening over the past three weeks. He is a painter and admits to working very long days over the past 2 months. He says “my wife thinks I’m just working too much. But I just feel very weak and I’m always tired and now I think I’m coming down with the flu.” The patient describes feeling nauseated without vomiting. Occasional constipation which he states is chronic. Now also having cramping abdominal pain over the past few days with no appetite.
His vital signs are normal. He has no significant PMHx and takes no prescription or OTC medications. He is a social drinker and denies tobacco or recreational drug use.
As you begin your physical exam you exam his oral mucous membranes.
1. What are your initial thoughts as you examine his mouth and dentition?
2. What should you consider given his occupation?
3. What additional physical or laboratory findings might raise your suspicions?