3. Chief complaints
H/O difficulty in swallowing – 6months
H/O food sticking in throat – 6months
H/O swelling over left side of neck – 2 months
H/O Change of voice – 1 week
4. History of presenting illness
Difficulty in swallowing
Insidous, gradually progressive, Initially for solids,
since last week for liquids also.
Associated with feeling of food being stuck in throat
on attempted swallowing.
Burning sensation of throat on taking spicy food
items.
Patient has increased salivation since last 1 week.
5. Swelling in left side of neck
Insidous, gradually progressive, initially size of pea
when first noticed, which later progressed to present
size of lemon.
No H/O sudden increase or decrease in swelling
No H/O pain over the swelling
No H/O discharge from the swelling.
7. H/O cough since 6 months, associated with yellowish
sputum, scanty, non foul smelling, non blood
stained.
H/O recurrent fever present since last 6 months,
associated with chills and rigors. More during
evening time.
H/O loss of appetite since 1 month
H/O loss of weight since 1 month
8. No H/O regurgitation of food on lying down.
No H/O cough on swallowing liquids.
No H/O bad smell from mouth.
No H/O earache, ear fullness, decreased hearing, ear
discharge.
No H/O Respiratory difficulty or noisy breathing
No H/O Haemoptysis, haematemesis, malena.
No H/O bone pains.
9. MEDICAL history
No H/O DM, HTN, TB, BA, Drug allergies,
prolonged medication, Blood transfusions.
10. Treatment history
Patient has not shown to any other doctor for the
present complaints.
Post admission patient has been put on symptomatic
treatment.
Iv fluids (RL and DNS)
Inj Rantac 150mg BD
Inj Diclo 50mg BD
Inj PCT 500mg TID
12. Personal history
Appetite – Decreased
Diet – Mixed
B&B – Regular
Sleep – Altered
Habits – 1 pack bidi everyday since last 40 years
(abstinence since 1 week)
Alcohol consumption (Brandy) around 250ml since
40 yrs. (abstinence since 1 week)
13. General examination
72 year old male patient, moderately built and poorly
nourished
Conscious, co operative, well oriented to time, place ,
person
VITALS:
BP: 120/80 mm hg
PR: 76/ MIN
RR: 18/ MIN
Pallor, clubbing , lymphadenopathy – Present
Icterus, cyanosis - Absent
14. Systemic examination
CVS: S1 & S2 heard , no murmurs
RS: B/L NVBS heard, no added sounds
P/A: soft, non tender, no organomegaly
CNS: normal
15. Local examination
Oral Cavity
Lips, Angle or mouth, GLS, GBS, tongue, floor of mouth
– Normal
Mouth opening – adequate
Teeth – Upper jaw edentilous, lower jaw lower central
incisors absent, rest are nicotine stained
Buccal mucosa, hard palate – Nicotine stained
RMT - Normal
Oropharynx –
AP, Tonsil, PP, Base of tongue, PPW – Normal
Palpation of base of tongue – Normal
17. Neck examination
Colour and appearance of skin – Normal
Laryngeal framework –
Inspection – normal, no widening, central, no
swelling.
Palpation – No swelling appreciated.
Laryngeal crepitus present
No tenderness
18. Lymph Node –
Inspection – Solitary smooth hemispherical Swelling
of size 2.5x2.5 cm present above left middle third of
SCM, margins well defined, no signs of inflammation
seen. (Level III)
Palpation – Inspectory findings confirmed, no local
rise of temperature, firm to hard in consistency, skin
over swelling pinchable, mobile from side to side,
immobile vertically.
19. EAR
RIGHT LEFT
Preauricular normal normal
Pinna normal normal
Postauricular normal normal
EAC normal normal
20. nose
Cold spatula test:
External appearance: normal
ARE Vestibule: normal
Left sided DNS
Turbinates pale
Mucosa normal
Paranasal sinuses: Non tender
PRE: NORMAL