38 old female with inability to open mouth, dysphagia since 2 months, pancytopenia and paraphyarngeal abscess
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Patient came with the cheif complaints of difficulty in opening of mouth since 2 months
Left ear pain since 2 months
H/o of difficulty in swallowing since one month
Hopi: patient was apparently asymptomatic 2 months back and underwent left lower molar dental extraction on june 12 and then got swelling of mouth and difficulty in opening the mouth
On 17th june, patient was taken to local dental hospital and forcefull opening pf mouth was done which casued left ear pain which is radiating to left side of neck
Later she took pain killer injections(unknown) from the local rmp pain used subcide while taking medication and later used to aggravate
And later visited ent hospital in suryapet and got know that it was ear problem
Later they approached kims dental hospital,they reffered the patient to kims i/v/ o pancytopenia
Pain aggravated hy movement of neck over back side of neck,
She has h/o of pain while swallowing in the throat since one month, taking only liquid s and soft foods from then
C/o of sob since one month, grade 2 NYHA , relieved on taking rest, no orthopnea,no PND, no chest palpitations, no blood in stools , no menorhagia, no hematuria,
C/o of fever for 3 days 15 days back, associated with chills amd rigors, relieved on taking medication
Past h/o : not a known case of HTN, DM, thyroid, epilepsy, TB, CVA, CA
Personal history HISTORY:
She is Married
She is vegetarian
She is consuming liquid diet from oast 2 months
sleep is adequate
Appetite normal
bowel and bladder movements are regular
She is a daily labourer
She wakes up 6 am and does her household works and has her breakfast and goes to farming work, and has her lunch, and comes back home at 5pm and does her household works, prepares dinner, has her dinner at 8pm and sleeps at 9pm
MENSTRUAL HISTORY:
Age at menarche:12 years
Cycle: 30/5 days, Normal flow.
OBSTETRIC HISTORY:
Age at Marriage: 19 years
She has No children
FAMILY HISTORY:
No similar complaints in family
CLINICAL IMAGES:
General examination:
On presentation: Patient conscious, coherent, cooperative, well oriented to time place and person.
Pallor present
No icterus, cyanosis, clubbing, edema,
cervical lympadenopathy??
Vitals:
Bp:120/80
Pr:130bpm
Rr:24cpm
Temp:98.2f
Grbs: 110mg/dl
Spo2:97%
SYSTEMIC EXAMINATION:
CVS:s1,s2 +
Rs:bae+
P/a: size of uterus:corresponding to 12wks
CNS: b/l pupils NSRL
R L
Tone: N. N
Power: 5/5. 5/5
Reflexes : B T S A K P
R: + + + + + Flexion
L : + + + + + Flexion
No neck stiffness
Kernigs negetive
Brudzinski negetive
INVESTIGATIONS:
Chest xray
Mri neck :
Endoscopy :
Serum ferritin
DIAGNOSIS : inability to open mouth,dysphagia since 2 months, pancytopenia and paraphyarngeal abscess
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