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Medical Case History Taking & Examination in ENT & Otorhinolaryngology

Medical Case History Taking & Examination ENT, Otorhinolaryngology

A. EAR 
(a) History Taking
A practitioner typically asks questions to obtain the following information about the patient :
1. Identification and demographics

  • Name,
  • Age,
  • Sex,
  • Address,
  • Occupation etc.

2. Chief complaint (CC)

  • Ear Discharge (Otorrhoea)
  • Hearing impairment – Duration etc.
  • Otalgia (pain in the ear)
  • Itching
  • Fever
  • Tinnitus

3. History of the Present Illness (HPI) 0r History of presenting complaint (HPC)

  • Details about the complaints, enumerated in the CC. i.e. All the above mentioned symptoms in CC have to be analyzed under the following heading.

e.g. Ear Discharge (Otorrhoea)

  • Onset – Sudden/Gradual
  • Duration – Continuous(Long duration or Short duration)/Intermittent
  • Type of Discharge – Watery discharge/Serosanguinous/Mucoid/Purulent/Mucopurulent/Bloody
  • Odour – Odourless/Foul smelling (Fishy smell)
  • Quantity – Copious/Profuse/Scanty

e.g. Hearing Impairment (Deafness)

  • Onset – Sudden/Gradual
  • Unilateral/Bilateral
  • Progressive/Fluctuating etc.

e.g. Otalgia (Pain in the Ear)

  • Onset – Sudden/Gradual
  • Duration – Short duration/Long duration
  • Nature of the Pain – Dull/Sharp/Throbbing pain
  • Relieving Factors & Aggravating Factors
  • Radiating Pain & Referred Pain (Otalgia)

e.g. Tinnitus

  • Duration – Short/Long
  • Nature – Continuous/Intermittent and fluctuant/Pulsatile
  • Relieving factors/Aggravating factors

4. Past Medical History (PMH)
Including

  • any previous surgery/operations e.g. time, place, what type of operation.
  • major illnesses or any current ongoing illness e.g. IHD, Heart attack, Asthma, HT, RHD, TB, Jaundice, diabetes. if diabetic, mention time of diagnosis, current medication, clinic check up).
  • history of trauma or accidents.

5. Family History

  • Any familial disease running in families especially those relevant to the patient’s chief complaint e.g. IHD, DM, HTN, Asthma.

6. Drug History (DH)

  • Always use generic name with dosage, timing & how long. i.e. now and past, prescribed and over-the-counter, allergies.

7. Social History (SH)

  • Smoking : amount, duration & type
  • Alcohol : amount, duration & type
  • Occupation, social & education background, ADL, social support, pets and hobbies.

8. Childhood diseases 

  • This is very important in pediatrics.

9. General Physical Examination (GHE)

  • Built
  • Nourishment
  • Orientation to time, place & person
  • Vital data : Pulse, Respiratory rate, Blood pressure, Temperature, Generalised lymphadenopathy, Cyanosis, Oedema

(b) Examination (Right & Left Ear)
External ear

  • Pre auricular region : Sinus, swelling, cyst, accessory tragus, lymph nodes
  • Pinna : Size, shape and position
  • Post auricular region : Swelling, scar, battle’s sign, griesinger’s sign, 3 point tenderness test
  • External auditory canal : Upwards, backwards, outwards

Tympanic membrane (Describe & identify normal anatomical landmarks)

  • Colour – Pink/Rising sun/Red/Bluish(Blood accumulation)
  • Cone of light,
  • Four quadrants, umbo,
  • Handle & lateral orocess of malleus,
  • Anterior & posterior malleolar folds,
  • Pars tensa – Retraction, Granulation, Blebs, Sclerotic patches, Perforation (type, margins, location, size, shape, edge, polyps etc.)
  • Pars flaccida,
  • Bony annulus,
  • Incudostapedial joint

Fistula test
Mastoid tenderness
Facial nerve
Tunning fork test (Rinne’s, Weber’s, Air bone conduction)
B. NOSE 
(a) History Taking
A practitioner typically asks questions to obtain the following information about the patient :
1. Identification and demographics

  • Name,
  • Age,
  • Sex,
  • Address,
  • Occupation etc.

2. Chief complaint (CC)

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