AC POLYP medical description of a patient

medical description

1. A CASE OF ANTROCHOANAL POLYP

2. PATIENT DETAILS:

3. CHIEF COMPLAINTS : The Patient came to the OPD with chief complaints of Difficulty in breathing,especially during night due to nasal obstruction on left nostril for past 4 months.

4. PRESENTING ILLNESS : The patient was apparently normal before 4 months,then she developed Unilateral nasal obstruction on left nostril for past 4 months which is Insidious in onset Slowly progressive Aggrevated by exposure to cold Relieved by taking medications Associated with breathing difficulties mainly increased during night No seasonal variation present

5. H/O Unilateral nasal discharge for the past 2 months which is Insidious in onset Mucoid Not foul smelling Not blood stained Aggrevated by taking ice water Relieved by taking medication No crust formation seen

6. H/o postnasal drip for past 2 months H/o change in voice for past 2 months No h/o headache No h/o sneezing No h/o cough No h/o epistaxis No h/o smell disturbance No h/o trauma No h/o facial pain No h/o snoring No h/o ear pain No h/o ear discharge No h/o tinnitus No h/o hearing loss No h/o dysphagia No h/o throat pain or irritation

7. PAST HISTORY : NO h/o similar illness in the past No h/o any chronic illness in the past

8. TREATMENT HISTORY : No h/o previous medical and surgical treatment.

9. PERSONAL HISTORY : Mixed diet consumer Normal bowel and bladder movements Normal sleep and appetite pattern

10. FAMILY HISTORY : No h/o allergy No relevant family history present

11. MENSTRUAL HISTORY: Menarche at age of 14 Regular cycle(3/28 days)

12. GENERAL EXAMINATION: Patient is conscious Comfortable Oriented to time,place and person Moderately built and nourished No pallor Not icterus No cyanosis No clubbing No lymph node and thyroid enlargement No pedal edema

13. VITALS: PULSE: 72 beats/min BLOOD PRESSURE :124/80 mm hg RESPIRATORY RATE: 16 /min TEMPERATURE: 98.4F HEIGHT: 153 cms WEIGHT: 58 kgs BMI: 24.8

14. SYSTEMIC EXAMINATION : Cardiovascular system : SI S2 heard. No murmurs heard Respiratory system : Normal vesicular breath sounds heard No added sounds heard Per abdomen examination: Soft No organomegaly present Central nervous system: No focal neurological deficit

15. LOCAL EXAMINATION : 1)EXAMINATION OF EXTERNAL NOSE : INSPECTION OF NOSE : Skin normal Nose seems to be broaden(widening of nasal bridge) No scar,sinus,skin discoloration,swelling,fistula,vesicles,signs of inflammation present C ontour-normal Root-normal Columella -normal Ala of nose-normal Tip of nose-normal Osteocartilagenous framework-normal

16. PALPATION OF NOSE: No raised temperature No tenderness No crepitations present 2)EXAMINATION OF VESTIBULE: No fissures No furuncle present No crusting seen No tumors present

17. 3)ANTERIOR RHINOSCOPY: Nasal septum-deviated to right side Nasal cavity-left nasal cavity apperars to be blocked Color of mucosa- pinikish red Mucoid discharge No crust formation Floor and lateral wall of nose-normal No reliable information about turbinates .

18. 4)POSTERIOR RHINOSCOPY: Shows Unilateral edematous mucous membrane on left nostril which is Gray white in color, pink congested mucosa covered with mucoid nasal discharge Smooth,grows posteriorly , globular mass filling the choana No pus /bleeding present

19. 5)FUNCTIONAL EXAMINATION OF NOSE: AIRWAY PATENCY TEST : COTTLE’S TEST- Negative COLD SPATULA TEST -Reduced fogging on left side COTTON WOOL TEST -Movement of cotton is slow on left nostril PROBE TEST- Soft and moved up and down with the probe and can be moved all around the polyp,does not bleeds on touch and no pain present

20. 6)EXAMINATION OF PARANASAL SINUS: MAXILLARY SINUS: Soft tissue of cheek,lips,lower eyelid,molar region has mild swelling Orbit and its content- normal Vision -normal Vestibule of mouth- normal Tenderness- present FRONTAL,SPHENOID,ETHMOIDAL SINUS: Normal

21. 7)EXAMINATION OF FACE -Normal 8)EXAMINATION OF THROAT- Normal 9)EXAMINATION OF EAR -Normal 10)EXAMINATION OF NECK: Normal No significant lymphadenopathy

22. SUMMARY:

23. ANTERIOR RHINOSCOPY -reveals blockage of left nasal cavity POSTERIOR RHINOSCOPY- Shows Smooth globular gray white nasal mass covered with nasal discharge seen grows posteriorly,filling the choana It is soft and can be moved up and down with the probe Reduced fogging on left side in cold spatula test Movement of cotton is slow on left nostril in cotton wool test

24. INVESTIGATIONS: Nasal smear and swab for eosinophil count Complete blood count Diagnostic nasasl endoscopy X ray paranasal sinus(water’s view) X ray of the neck lateral view(CRESCENT OR DODD SIGN SEEN) NCCT nose and paranasal sinuses

25. FINAL DIAGNOSIS :

26. TREATMENT PLAN FUNCTIONAL ENDOSCOPIC SINUS SURGERY(FESS) or INTRANASAL POLYPECTOMY

27. THANK YOU…