, PATIENT’S DETAILS
Name : T.J. IC no. : -
Age : 60 years old Address: Kampung Tebedu, Serian
Gender : Male Marital status : Married
Race : Bidayuh
HISTORY TAKING
Chief complaint
A 60 years old gentleman, known case of Nasopharyngeal carcinoma diagnosed since April 2021,
presented to the ENT clinic for follow-up with no active complaints. Initially, he presented with
intermittent right epistaxis for eight months and bilateral neck swelling for 3 months.
History of Presenting Illness
Mr TJ was generally well until August 2020 when he experienced intermittent epistaxis from
his right nostril. He would have this epistaxis for 1 to 2 episodes per week. The bleeding was said to
be mixed with his nasal mucous membrane in minimal amount of blood streaks or tinge only.
Sometimes, he did experience spontaneous bleeding, however the bleeding would stop after
staining half of one tissue paper. Occasionally, the blood was also mix with his saliva and
expectorant. Associated together with the epistaxis, he would have frequent right nasal block of
unknown causes, bilateral neck swelling, left ear discharge with hearing loss, and halitosis.
Otherwise, he did not experience any anosmia, rhinitis, and upper respiratory tract infection (URTI)
symptoms. There was also no history of trauma to the nose, face, or neck.
Regarding his neck swelling, it was bilateral at the posterior triangle of his neck, most likely
affecting the Level III nodes. The neck swelling started later than the epistaxis, around January 2021.
According to Mr TJ, the size of the swelling was approximately the size of a 50-cent coin. It was
painless, hard, and did not change in size. Otherwise, he did not experience obstructive symptoms
such as difficulty swallowing, difficulty breathing, changes in voice quality, or hoarseness of voice.
There were no neck pain, sore throat, and trismus.
As for his ear problems, he admitted to having some disturbances in his left ear around the
same time he noticed his neck swelling, which was back in January 2021. There were minimal
discharge coming from his left ear. It was whitish and mucopurulent in nature. There was a mild
itchiness and tinnitus following the discharge. The ear disturbances progressed to the point where
he noticed some degree of hearing loss over his left ear. Otherwise, he did not have any otalgia.
Systemic review
Generally, Mr TJ did not have any fever, no constitutional symptoms, and no B-symptoms. Other
systems were generally well and normal. Upon further questioning, Mr TJ revealed that he noticed a
palpable breast lump felt at his left areola since last 2 weeks. It was non-tender, non-discharging,
and non-mobile.
Past medical history
Patient was diagnosed with Nasopharyngeal carcinoma since April 2021. He had completed the
initial course of concurrent chemotherapy (CCRT) until November 2021. Currently, he is undergoing
another course of chemotherapy and follow-up because of the metastases from the NPC. Otherwise,
he did not have any other underlying medical illness.
Name : T.J. IC no. : -
Age : 60 years old Address: Kampung Tebedu, Serian
Gender : Male Marital status : Married
Race : Bidayuh
HISTORY TAKING
Chief complaint
A 60 years old gentleman, known case of Nasopharyngeal carcinoma diagnosed since April 2021,
presented to the ENT clinic for follow-up with no active complaints. Initially, he presented with
intermittent right epistaxis for eight months and bilateral neck swelling for 3 months.
History of Presenting Illness
Mr TJ was generally well until August 2020 when he experienced intermittent epistaxis from
his right nostril. He would have this epistaxis for 1 to 2 episodes per week. The bleeding was said to
be mixed with his nasal mucous membrane in minimal amount of blood streaks or tinge only.
Sometimes, he did experience spontaneous bleeding, however the bleeding would stop after
staining half of one tissue paper. Occasionally, the blood was also mix with his saliva and
expectorant. Associated together with the epistaxis, he would have frequent right nasal block of
unknown causes, bilateral neck swelling, left ear discharge with hearing loss, and halitosis.
Otherwise, he did not experience any anosmia, rhinitis, and upper respiratory tract infection (URTI)
symptoms. There was also no history of trauma to the nose, face, or neck.
Regarding his neck swelling, it was bilateral at the posterior triangle of his neck, most likely
affecting the Level III nodes. The neck swelling started later than the epistaxis, around January 2021.
According to Mr TJ, the size of the swelling was approximately the size of a 50-cent coin. It was
painless, hard, and did not change in size. Otherwise, he did not experience obstructive symptoms
such as difficulty swallowing, difficulty breathing, changes in voice quality, or hoarseness of voice.
There were no neck pain, sore throat, and trismus.
As for his ear problems, he admitted to having some disturbances in his left ear around the
same time he noticed his neck swelling, which was back in January 2021. There were minimal
discharge coming from his left ear. It was whitish and mucopurulent in nature. There was a mild
itchiness and tinnitus following the discharge. The ear disturbances progressed to the point where
he noticed some degree of hearing loss over his left ear. Otherwise, he did not have any otalgia.
Systemic review
Generally, Mr TJ did not have any fever, no constitutional symptoms, and no B-symptoms. Other
systems were generally well and normal. Upon further questioning, Mr TJ revealed that he noticed a
palpable breast lump felt at his left areola since last 2 weeks. It was non-tender, non-discharging,
and non-mobile.
Past medical history
Patient was diagnosed with Nasopharyngeal carcinoma since April 2021. He had completed the
initial course of concurrent chemotherapy (CCRT) until November 2021. Currently, he is undergoing
another course of chemotherapy and follow-up because of the metastases from the NPC. Otherwise,
he did not have any other underlying medical illness.
