Patient Details
|
Name |
Stephen Cotter |
|
Age |
64 |
|
Sex |
M |
|
Medications |
Pantoprazole 40mg OD |
|
HPC |
Patient has presented with three-month history of progressive gravely voice along with dysphagia for solids, odynophagia and right-sided otalgia. He has no cough or haemoptysis. He has had no history of recent URTI or steroid inhaler use. He has never had significant trauma to chest/ neck or intubation. He has no other significant systemic illness. On examination with the GP, they noticed a gravely voice (changed from previous visits) and a palpable painless right-sided neck lump. The GP then made an urgent referral to the nearest ENT surgeon for investigation with flexible laryngoscopy. |
|
PSxHx |
Nil |
|
PMHx |
GORD |
|
Allergies |
Ibuprofen – reaction: diffuse hives, no anaphylactoid reactions |
|
FHx |
Mother is alive and living in a nursing home with dementia. Father died at age 62 following an ischaemic stroke. The patient’s younger sister was diagnosed with type 2 diabetes three years ago. There is no family history of cancers. |
|
SHx |
Patient lives with his wife and twin boys (22yrs) in Armidale. Has an 80 pack year smoking history and continues to smoke two packs a day. Drinks half bottle of wine with wife each night and four or five pints of full strength beer at the pub with old work colleagues on a Friday night. |