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)
