46 yr female with painfully inflamed tonsils and gastric issues

NOTE:  THIS IS AN ONLINE E LOGBOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT

PATIENT HISTORY: Pt is a 46 yr old lady who currently works as a power press operator in a steel cutting unit. In October 1995, she had a high fever episode lasting for 7 days. Symptoms shown were high fever, lightheadedness, loss of appetite, extreme weakness, severe loss of wt., and low Hb. Though widal test was not performed, since at that time her colony was having an outbreak of typhoid, Dr. suspected the same and she was treated with medications. Although her fever decreased 7 days later, she continued feeling dizzy with blurry vision, lightheadedness, and general body weakness for 1 month. 

Got married in Oct. 1995. In 1997 Jan, gave birth to her first son. 7 months after her first child was born, she got pregnant, but after 6 wks of gestation approx the family decided to get it aborted, due to personal issues. She was given medicine by a pediatrician for a medical termination. But after starting taking medicine for abortion they decided to not terminate the pregnancy. But, Dr. said it's already too late. So, they went to another Dr. who said abortion is the only option. After the abortion, she felt very weak, with SOB, and low Hb. Gradually recovered from weakness.

 Since that time during the menstrual cycle, she used to experience menorrhagia and menstrual cramps which were so intense that she used to be completely bedridden at that time for 9 days. No treatment was done for it until 2002. In 2002, she went to Dr. who prescribed medications. After taking medication for 2 yrs with no notable improvement, on further investigation fibroids in the uterus were detected. Dr. advised for Sx but pt opted for homeopathy treatment for 2 yrs. No improvement. In 2008,  hysterectomy was done. Afterward, she complained of burning micturition which got relieved by drinking a lot of water and medications. 

Suffering from episodes of gastric problem(feeling of fullness, indigestion) since 1997, when pt came to Hyderabad for work. Suspected etiology - Used to cook food in badam oil and also ate spicy foods at that time. 

In  2014, while working in the chemical department, she noticed her urine was yellow most of the time, b/l pedal edema, and low Hb.  Went to Dr. On taking prescribed medications pedal edema reduced. But urine still yellow and Hb low. So, on the recommendation of a family quark took a syrup which increased Hb lvl and urine returned to normal color. She believes that the chemicals with which she worked can be the possible etiology for these symptoms. So, she left that department and went to the power pressing department.

Fo the past 2 - 2.5 yrs, frequent episodes of migraine (once a wk or once in 15 days). Resolved with medications. Possible etiology tension and work pressure and working for long hours in a very noisy environment. 

In early 2020, she had an episode of fever and b/l swelling of the tonsils which was very painful and made swallowing difficult, with a burning sensation in the throat. Got to know from mother that she used to have frequent episodes of fever, cough, and cold with inflamed and painful tonsils since childhood and used to get cured with medications. Her swelling of tonsils and pain with burning sensation aggravated if she ate sweet items and relieved on gurgling. For the last 7 months, difficulty sleeping at night due to increased cough and dryness of the throat and tongue.  6 months back she started complaining of excessive daytime sleepiness due to a lack of proper sleep at night (frequently woke up due to coughing). She went to ESI hospital, where she was diagnosed of having chronic tonsillitis for which she was on medication - T. Amoxiclav, T. Levocet 5mg, T. Pan 40mg. After taking the medication she developed a burning sensation in the epigastrium which got relieved with T. Pan 40mg. She also developed back pain due to long hours of sitting in her workplace for the past 2 yrs, but it increased for the last 6 months, for which she again went to ESI hospital, where she was prescribed analgesic and pain was relieved. High cholesterol lvl detected 6 months ago.

On June 4th, she was diagnosed with grade 2 tonsillar hypertrophy with acute gastritis. b/l tonsillectomy was done.

She is non diabetic, non HTN with no addictions

 CURRENT CHIEF PROBLEMS  AND PATIENT'S REQ.: After tonsillectomy, she complains of throat pain on eating curd, and sour food (using tomato, and tamarind in making dishes). But while eating raw tomatoes no problem. 

FAMILY HISTORY:

Father - died at age 62, yr 2008. Appendix Sx. Had DM, 3 heart attacks. Died due to a heart attack. Used to chew tobacco

Mother - Appendix Sx, gallbladder ?stone Sx

DIAGNOSIS : Right grade 2 tonsillar hypertrophy with acute gastritis

TREATMENT : b/l Tonsillectomy done

PREVIOUS TREATMENT COURSE AND DISCHARGE SUMMARY: