38y F with inability to open her mouth, dysphagia since 2 months, pancytopenia and parapharyngeal abscess
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A 38-year-old female presented with the chief complaints of difficulty in opening her mouth and left ear pain since 2 months, and difficulty in swallowing since 1 month.
History of Presenting Illness:
Sequence of events:
12th June, 2023: The patient had her left lower 2nd molar extracted for caries which was causing a toothache.
16th June, 2023: She first experienced difficulty in opening her mouth coupled with severe pain (she rated the pain as 9/10). Both of these symptoms were insidious in onset and have been progressing since then.
17th June, 2023: She was taken to local dental hospital where forceful opening of her mouth caused left ear pain which radiated to the left side of her neck.
She used some unknown painkiller injections prescribed by a local RMP during this time. Her pain responded to these injections but aggravated on prolonging the interval between them. She took a total of 4 of these injections.
3rd week of June: She visited one other hospital, where she was referred ti an ENT specialist for further examination. No treatment was prescribed here and patient did not take any new medications.
July, 2023: She started having difficulty and pain while swallowing both solids and liquids.
She also started experiencing shortness of breath (Grade II NYHA) which was relieved on rest.
No orthopnea, PND, chest pain or palpitations. No blood in stools, hematuria or menorrhagia.
July 26th, 2023: Low grade fever that was insidious in onset, non progressive, assosciated with chills and rigors. Lasted for 3 days. Relieved on medication (paracetamol).
August 2023: The patient arrived at the local dental hospital for further relief from her symptoms but was referred to the medicine department in view of pancytopenia.
8/8/23: A referral by the department of ENT was done on 8/8/23.
Findings: Mild anterior DNS to the left, grade III trismus, ulcerated left lateral pharyngeal wall.
Advice: Patient was referred to OMFS, asked to get Xray of head and neck in AP and lateral views and an MRI.
9/8/23: A referral by the department of Oral and Maxillofacial surgery was done on 9/8/23.
Findings: Dental fluorosis, TMJ dysfunction with decreased mouth opening (2 fingers breadth) , dental caries.
Suspicion of parapharyngeal abscess (?)
Advice: physiotherapy (mouth opening exercises) , VOVERAN and FLEXON MR.
Patient asked to return to the dental OPD in 5 days for review.
History of past illness:
Not a known case of HTN, DM, Asthma, TB, Epilepsy, CAD, CVD
Medication History:
Uses homeopathic medications for headaches, used unknown analgesic injections during the course of her treatment outside the hospital.
Personal history:
Decreased appetite, diet has mostly been soft and liquid.
Bowel movements: 1/day, normal in consistency.
Urine output: 2-3/day, no burning on micturition.
Moderate drinker, drinks 1 glass of toddy once every 10 days. She has been drinking for the past 6 years.
She does not smoke, chew tobacco/gutkha/pan masala. No other addictions/substance abuse.
Food and drug allergies: No known allergies.
Menstrual and obstetric history:
Menarche: 12yrs of age
Cycle: 5/30, normal flow, regular.
Age at marriage: 19 years.
No children.
Daily routine:
Prior routine:
Agricultural labourer by occupation who lives with her husband. She works on roughly 4 out of 7 days a week. She wakes up at 5am, starts her day by cleaning her house and yard, cooking meals and drinks a cup of chai at 6am with her husband. She has her first meal at 8am and leaves to work at 9am on foot. The field she works in is roughly half a kilometre away from where she lives. Here she spends most of her time either sowing seeds, husking grain or weeding. She takes a 30 minute nap near the field itself at 1pm, wakes up and has lunch at 2pm. She goes back home between 5-6pm and cooks dinner. She has dinner between 7-8pm and goes to bed between 9-9:30pm. She considers her physical activity levels as moderate (described by her as not too much but not too little either).
Routine since the onset of her illness:
She has not been going to work. She has had a severe loss of appetite and some sleep disturbance. She wakes up at 6:30am, cooks and cleans her house. She has not been having solid food for the past 1.5-2months. For breakfast she tries to eat soft foods like mashed khichdi or powdered idlis, and drinks 2 glasses of jowar water at roughly 3pm and 8pm. She goes to bed at 9pm.
Family History
No similar complaints in her family.
General physical Exam:
On admission:
Vitals:
Afebrile (101.2F)
BP: 100/70mmHg
HR: 80bpm
RR: 20cpm
SpO2: 97% on RA
GRBS: 90mg/dL
Patient is conscious, coherent and cooperative, well oriented to time, place and person.
Conjunctival pallor +
No signs of cyanosis, icterus, lymphadenopathy, clubbing or pedal edema.
JVP normal
Systemic exam:
Cardiovascular System: S1, S2 heard, no murmurs.
Respiratory System: BAE+, VBS, stertor+ at the time of examination,
Per Abdomen: Soft and nontender, no organomegaly.
CNS: C/C/C, AOx3, no focal neurological defects, CN function intact.
CNS: B/L pupils NSRL
Tone: N. N
Power: 5/5. 5/5
Reflexes : B T S A K P
R: + + + + + Flexion
L : + + + + + Flexion
No neck stiffness
Kernigs negative
Brudzinski negative
Investigations:
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