Wednesday, 3 March 2021

Med. e-log case 2

33 year old female with recurrent oral ulcers 

Farmer by occupation ,

Chief complaints of recurrent oral lesions since 10 months 

HOPI - patient was apparently asymptomatic 10 months back and then developed a small red coloured lesions on the left side of the oral cavity which was painful and in the following days , the new lesions are developing .
She took some treatment and no fresh lesions are seen up to 1 month. But after a month again new lesions are seen 
Aggravating Factors - Spicy foods 
Relieving factors - Medications.
 PAST HISTORY - No h/o such lesions in the past 
NOT A KNOWN CASE OF HTN, DM, BA, TB, EPILEPSY . 
NO OTHER KNOWN COMORBIDITES .

GENERAL EXAMINATION : PT IS C/C/C ORIENTED TO TIME , PLACE AND PERSON .

NO PALLOR , CYANOSIS, LYMPHADENOPATHY , CLUBBING , ICTERUS , EDEMA .

 ON LOCAL EXAMINATION -
MULTIPLE LESIONS OVER THE BUCCAL MUCOSA AND HARD PALATE and  WHITE COATED TONGUE .

SYSTEMIC EXAMINATION - 

CNS : GCS 15\15 , NO ABNORMALITY DETECTED.

CVS - S1,S2 HEARD , NO MURMURS .

RS : NVBS HEARD , NO ADDED SOUNDS .

P/S : VAGINAL MUCOSA  WITH CURDY WHITE DISCHARGE .

Investigations - 
SERUM ELECTROPLYTES : Na : 137 m Eq /L , K : 4.7 mEq /L , Cl : 107 mEq /L .

CUE : ALB : + , SUGARS : NIL , PUS CELLS : 3-4 , EPITHELIAL CASTS : 2-3.

HIV : NON REACTIVE 

Provisional diagnosis : 
RECURRENT ERYTHEMA MULTIFORME  SECONDARY TO HSV

? CHRONIC APHTHOUS ULCERS 

? BECHETS DISEASE

? CHRONIC CANDIDIASIS.

Treatment given initially - 
1] DNS  -3

2] ORS SACHETS

3] INJ. PAN -D OD BBF

4] WARM SALINE GARGLES

5] INJ. PCM IV SOS

6] WATCH FOR BREATHING DIFFICULTY

7] PLENTY OF ORAL FLUIDS

8] TAB. ACELO-P  BD

9] TAB. OFLOX -OZ 200 MG BD

10]  SYP. CREMAFFIN 15 ML H/S

11]  OINT. ANOBLISS  L/A ANAL REGION
 
Treatment given at present - 
1) IV fluid NS @ 50 ml/hr
2) Inj.TRAMADOL 1 ampule in 100ml NS IV over 30min
3) Syp MUCAINE GEL 10ml/ PO / TID

PRESENT CONDITION : The patient had pain relief after medication 

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