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Abstract: The patient in this case is a 48-year-old middle-aged female who started to have ulcers on the oral mucosa a few months ago with severe pain and inability to eat salty and spicy food. the ulcers recovered in about 2 weeks, but ulcers appeared again in another place in the mouth, which was more painful for the patient and affected her normal life. The patient was diagnosed with oral aphthous ulcer according to his clinical manifestations and auxiliary examinations. After giving medication, the ulcer healed and the pain was relieved.
Basic information】Female, 48 years old
Type of disease】Oral aphthous ulcer
Hospital】The Second Affiliated Hospital of Nanchang University
Date of consultation】May 2022
Treatment plan】Medication (recombinant bovine basic fibroblast growth factor topical gel, rehabilitation new liquid)
Treatment Period】7 days of outpatient treatment
Effectiveness】healing of ulcer surface, pain relief, no recurrence
I. Initial consultation
The patient is a 48-year-old woman who came to our hospital in a poor state of mind, and after careful questioning of her medical history, we learned that several months ago, she had recurrent mouth ulcers, sometimes one, sometimes several, and used Guilin watermelon cream on her own, after which she felt that the pain on the ulcer surface was reduced, and each ulcer would heal on its own in about 2 weeks. 1 week ago, multiple ulcers appeared in her mouth, and she felt unbearable pain and came to the hospital for He came to the hospital for treatment. On examination: multiple ulcers of about 5x5mm in size, with clear borders, soft texture and pain when touched were seen on the mucosa of the lower lip, tip and root of the tongue. Patient’s self-report: 1 year ago, due to family reasons, mental stress, often sleep late, usually like to eat salty, spicy and other heavy food, denied the history of systemic diseases, smoking history, and drug allergy history. The patient was diagnosed with oral aphthous ulcer based on clinical manifestations and ancillary examinations because of the characteristics of superficial ulcers and multiple, self-healing ulcers in the mouth.
(Body check)
II. Treatment history
Most of the causes of oral aphthous ulcers are the result of a combination of multiple factors, such as low immunity, lack of trace elements, and anemia can cause them, so the patient was examined for trace elements and immune function. After completing the relevant tests, no significant abnormalities were found in the evaluated condition and test results, and the initial consideration was that it was caused by lifestyle habits and excessive mental stress. Therefore, the patient was given topical medication and topical application of recombinant bovine basic fibroblast growth factor topical gel to promote the healing of the ulcer surface, together with the use of rehabilitation new liquid mouth rinse, and the patient was instructed to eat a light diet.
III. Treatment effect
The oral aphthous ulcer will gradually heal after 1-2 weeks, and the patient was asked to come back to the hospital in 1 week to see the wound surface of the original large ulcer shrinking, the wound surface of the small ulcer basically healing, the redness and swelling decreasing, the pain basically disappeared, and the patient felt good. The patient was instructed to continue to use the medication and eat a light diet until the ulcer was healed, and after 1 month, the patient was followed up by telephone.
IV. Notes
Although oral aphthous ulcers can heal spontaneously, the onset of the disease can cause pain and affect the patient’s speech and food intake. Therefore, it is important to consume more vitamin-rich foods such as vegetables and fruits in daily life, eat a light diet, and avoid eating foods that are too spicy and stimulating. Pay attention to the protection and cleaning of the oral cavity, brush and rinse the mouth on time, and keep the mouth moist. Patients should also maintain a good state of mind, work and rest on time, and develop good habits. They can also take multivitamin tablets for a period of time to supplement vitamins. If the ulcer is large, the ulcer is hard to the touch, and it has not grown well for 1 month, you need to come to the hospital for further examination.
V. Personal insight
Oral aphthous ulcers are very common in daily life, and the factors of development include immune factors, genetic factors, systemic disease factors such as gastric ulcer and duodenal ulcer, and environmental factors, living and working environment, social environment, and psychological factors. In this case, the onset of the patient was considered to be related to lifestyle habits and excessive mental stress. For treatment, wound healing drugs are given, along with vitamins. In daily life, patients should maintain a good mood and healthy habits. However, it should be noted that if the oral ulcers in the same location do not heal for more than 1 month and become more and more serious, it is necessary to be alert to the possibility of oral cancer and need to go to the hospital in time.