Case of a 46 years old female with throat pain.
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REFERENCE - https://ssahamedicalcases.blogspot.com/2022/07/patient-history-pt-is-46-yr-old-lady.html?m=1
This is the case of a 46 years old lady, who is a power press operator by occupation and a resident of Hyderabad.
CHIEF COMPLAINT
The patient has the chief complaint of
HISTORY OF PRESENTING ILLNESS
The patient was apparently asymptomatic 3 years ago, 3 years ago, she started experiencing epigastric pain and discomfort. The pain was of the burning type and occured usually after eating anything. It aggravated on eating greasy and spicy food and relieved on taking medication. Since then she has had one episode of epigastric pain and discomfort every day. For the past 1 year, the pain has aggravated. The patient thought the pain was due to an increased intake of painkillers, which she was taking after an accident 3 years ago.
The patient had a history of inflamed and swollen tonsils for the past 3 years. It was associated with yellowish-white discharge and difficulty in swallowing.
In early 2020, her tonsilitis aggravated due to multiple episodes of cold. It was associated with enlarged tonsils and a burning sensation in the throat. On going to a hospital she was diagnosed with chronic tonsillitis and was told that she would have to undergo a tonsillectomy. She went to another hospital where her tonsillectomy was done.
Following the tonsillectomy, her throat pain did not subside. The pain was of a burning type, continuous in nature, aggravated by eating sour and sweet food and relieved by drinking hot milk and taking medication for her dyspepsia .It was not associated with difficulty in swallowing. The patient complained of the throat appearing red and inflamed. She also has multiple episodes of fever with chills occurring at night which are relieved by taking paracetamol. She went to a hospital where she was given Azithromycin 500 for her throat pain which she took for 2 days, as she didn't get any relief.
HISTORY OF PAST ILLNESS
She has had a history of high cholesterol from 5 years, for which she took medication for 1 year and then discontinued it.
She has a history of migraine, for which she takes medication.
Not a known case of DM, hypertension, asthma, TB, Thyroid condition, or Epilepsy.
SURGICAL HISTORY
2008- Hysterectomy - due to uterine fibroids
2022- Tonsillectomy- for chronic tonsillitis.
FAMILY HISTORY
Father - Was a known case of HTN , DM , CVD
Mother - Is a known case of HTN, DM , CVD
PERSONAL HISTORY
DIET- Mixed diet
APPETITE- Normal
SLEEP- Adequate
BOWEL AND BLADDER MOVEMENTS - Normal
ADDICTIONS- none
ALCOHOL- no
SMOKING- no
ALLERGIES- none
PREVIOUS INVESTIGATIONS
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