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患者姜某,男,58岁,本省某山区人。患者20天前取下上全口义齿清洁时,发现上腭部溃烂,并与鼻腔相通,导致语言不清,进食饮水不便,溃烂区无痛,但觉右上颌窦区轻微胀痛,在当地肌注青霉素四天,每天一次,每次40万单位,无效。 该患者结婚2次,前妻离婚,后妻已故,生育一女,其女发育良好。20年前有冶游史。 全身体检无特殊,口内检查:上颌无牙合,硬腭中部可见2.5cm×4cm溃疡面,溃疡两侧边缘至54|45区牙槽嵴粘膜,后缘距硬软腭交界处1.5cm,前缘距门齿孔1.2cm,溃疡边缘微隆起,界线清楚,周围粘膜正常,溃疡表面有少许淡黄色分泌物
Patients Kang, male, 58 years old, a mountain person in the province. Patients removed 20 days ago on complete denture clean, found on the palate ulceration, and communicating with the nasal cavity, resulting in unclear language, drinking water inconvenience, ulceration painless, but feel right maxillary sinus area slight pain, local Intramuscular injection of penicillin four days, once daily, each 400,000 units, invalid. The patient was married 2 times, his ex-wife was divorced, his wife was late, had a daughter, and her daughter was well-developed. Twenty years ago, there was a tour history. Whole body examination no special, intraoral examination: maxillary non-occlusal, the middle of the hard palate visible 2.5cm × 4cm ulcer surface, both sides of the ulcer edge to 54 | 45 alveolar ridge mucosa, the back edge of soft palate junction 1.5cm, leading edge distance Cervical hole 1.2cm, micro-ulcer edge uplift, clear boundaries around the normal mucosa, ulcer surface a little yellowish secretions