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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