38 old female with inability to open mouth, dysphagia since 2 months, pancytopenia and paraphyarngeal abscess

August 09, 2023

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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

General examination:

On presentation: Patient conscious, coherent, cooperative, well oriented to time place and person.

Pallor present

No icterus, cyanosis, clubbing, edema,