Case Presentation in Nose.pptx

Case Presentation proforma in Nose for MBBS students

1. Case Presentation in Nose. Dr. Rajashri Mane, Prof & HOD, D. Y. Patil Medical College, Kolhapur.

2. CASE HISTORY Name: Age Sex: Socioeconomic status: Occupation

3. NOSE Chief complaint Nasal obstruction Nasal discharge

4. Nasal obstruction Unilateral/bilateral Intermittent/continuous Progressive/static Aggravating/relieving factors Diurnal variation Positional variation

5. Unilateral continuous DNS AC polyp F B Neoplasm Rhinolith rhinosporidiosis Unilateral intermittent Turbinate hypertrophy sinusitis

6. Bilateral continuous DNS & Inferior turbinate hypertrophy Ethmoid polyps Adenoids Atrophic Rhinitis Rhinoscleroma Neoplasm

7. Bilateral intermittent Allergic Rhinitis sinusitis

8. Nasal discharge Watery/ mucoid / mucopurulent /blood stained Foul smelling/non foul smelling Unilateral/bilateral Aggravating/relieving factors-at time of URTI/exposure to cold environment

9. Watery -- Allergic Rhinitis vasomotor Rhinitis CSF Rhinorroea Purulent – sinusitis Faul smelling – Atrophic Rhinitis FB in children Malignancy in adults

10. History of complication History of Epistaxis Sneezing( Allergic rhinitis ) Watery discharge( CSF Rhinorrhoea ) crusting/dryness/foul smell( Atrophic rhinitis ) headache/post nasal discharge( Sinusitis )

11. Throat pain/ odynophagia / halitosis/ dry cough Ear discharge/ pain / deafness

12. History of etiology History of Trauma Surgery

13. Associated ear complaints-ear discharge/ear blockage/diminished hearing Associated throat complaints -sore throat/pain in throat/difficulty in swallowing/change in voice Treatment history - Medical-tablets/injections/local nose drops Surgical

14. Past history History suggestive of TB/ HTN/HIV/ DM/Any other illness. Family history History suggestive of TB/ HTN/HIV/ DM/Any other illness. Personal history -Nutrition: adequate/ inadequate -Diet: Veg / Nonveg /Mixed - Sleep: Normal/Reduced -Habits: Smoking/ tobacco chewing/ alcohol Days/ months/years History of exposure to noise History of exposure to S.T.D’s

15. General physical examination : - Built: good/ moderate/poor -Adenoid facies -Pallor/cyanosis/jaundice/clubbing/ Lymphadenopathy / edema - Pulse rate- /minute -B.P. mm Hg Systemic examination - - CVS -RS - CNS - P/A

16. NOSE EXAMINATION External appearance Inspection Palpation Root, dorsum, tip, ala, collumella Cold spatula test Vestibule

17. Anterior rhinoscopy(ARS): Nasal mucosa- pale/congested/bluish Septum- deviated/straight/perforated Lateral wall- inferior and middle turbinates & meati Floor-Any growth/polyp/presence of mucopus

18. Posterior rhinoscopy(PRS): Choana ET orifice Fossa of Rosenmuller Roof of nasopharynx Soft palate

19. Paranasal sinus(PNS): Inspection- oedema/ cellulitis Palpation- tenderness of frontal/ethmoid(R/L)/maxillary(R/L)

20. PROVISIONAL DIAGNOSIS Deviated nasal septum to right/left with caudal dislocation to right/left with right/left/bilateral spur in floor with right/left sided ITH with no/CSOM/Sinusitis/ adenotonsillitis pathology in ear/throat.

21. INVESTIGATIONS Diagnostic Nasal Endoscopy X ray PNS waters view

22. NOSE-deviated nasal septum Active infection-conservative treatment- antibiotics Antihistaminic Nasal decongestant ( local & systemic) Anti inflammatory Nose drops After acute infection subsides-surgery-Septoplasty Inactive- surgery- Septoplasty under local anesthesia with sedation.

23. Thank You.