Case presentation on oral ulcer with severe stomatitis - useful for medical students, pharmacy students, for covering the case reports required during their education. Includes basic information about the disease, subjective evidence, chief complaints of the patient, vital signs, objective evidence, laboratory data, assessment, provisional diagnosis, final diagnosis, treatment chart ,planning and medications given to the patient during his/her stay in the hospital.
2. ABOUTTHE
DISEASE
Recurrent painful ulcers on the non-keratinized
oral mucous membranes.
Due to infectious pathogens such as bacteria,
fungi or viruses .
Also due to allergy
Triggers :
mouth injury
Stress
Some foods
3. SUBJECTIVE
EVIDENCE
IP NO :- 2832
AGE :- 38YEARS
GENDER :- MALE
DEPARTMENT :- DELUX ROOM
DOA :- 24/3/23
7. ASSESSMENT
A 38 year old male patient came to the hospital and was admitted
with c/o severe mouth ulcers , fever, throat pain, difficulty in
swallowing, reduced appetite, dizziness.
FINAL DIAGNOSIS :-
Mouth ulcer with stomatitis
8. PLANNING
DAY 2 – 25/3/23
Same as day 1, Infupar – IV drip (SOS)
DAY 3 – 26/3/23
Same as day 2, Dynapar – 1 ampoule of 100 ml – IV drip (SOS)
Medication prescribed Dose Frequency
Torixone 2 mg For 1 hour with NS IV
Emset 4 mg OD
Razo 20 mg OD
Dynapar 2 cc In 100 ml NS IV
RI 500ml/IV 500 ml OD
NS 1000ml/IV 1000 ml OD
DAY 1 - 24/3/23
