History taking in a case of CSOM with central perforation

History taking in a case of CSOM with central perforation

1. HISTORY TAKING IN ENT ----- SAYAN BANERJEE

2. A case of CSOM with central perforation ( Tubo -tympanic disease)

3. PATIENT PARTICULARS Name Age Sex Religion Occupation Address Date of admission Today I am going to present the history of (age) year old, male/female (name) . He/she is a (religion) by religion and works at/as (occupation) in (city) and is a permanent resident of (address) .

4. CHIEF COMPLAINTS He/she presented in the out patient department of ENT with chief complaints of:- In chronological order : Disease which started first. Right ear discharge – 2 years. Difficulty in hearing – 1 year. Ringing sensation in ear – 6 months. Fever – 1 week.

5. H/O PRESENT ILLNESS Patient was apparently alright 2 years back when he/ she started with (complaint). First describe the 1st chief complaint then its associated symptoms and relevant negative history. Then go on 2 nd chief complaint and like wise. Then negative history of overall disease picture. Patient was apparently alright 2yrs back when he/ she started with discharge from right/ left ear, which was primarily serous/ mucoid in nature, but gradually became purulent with sensation of ear fullness over 10 days duration. The discharge is n on-offensive, copious in amount, mostly appears at the time of URI or on entry of water in the ear. He/ She experienced similar episodes for about 6-7 times in last 2yrs. He/ She has a positive h/o pond-bathing for about 10-12yrs prior to the onset of his/her symptoms. She had experienced earache in her 1 st 2-3 episodes, but the earache gradually diminished and now at the time of presentation, there is no earache. He/ She has also developed u/l (Rt/ Lt) ear deafness since last 1yr with intermittent episodes of vertigo (not much significant). He/ She also complains of ringing sensation/ tinnitus in both ears (Rt & Lt) since last 6 months, which is continuous & non-pulsatile in nature. He/ She also has fever at the time of presentation, which is since last 1wk, which is intermittent in nature, of mild - moderate grades, may occur at any time of the day. There is no h/o injury to the ear or vomiting or itching or lacrimation or facial palsy a/w his/ her symptoms.

6. H/O PAST ILLNESS • History of Tuberculosis/ Syphilis/ Leprosy/ Epilepsy. • History of infectious fever - Measles/ Chicken pox/ Typhoid. • History of trauma or allergy. • Any history of previous surgery. • History of diabetes and hypertension. • Diseases of CNS & Others. FAMILY HISTORY • Members of family. • Similar complaints in any other member in the family. • History of T.B./Diabetes/ Hypertension in any family member. • Duration. • Onset.

7. PERSONAL HISTORY • Diet/ Sleep/ appetite • Micturition/ bowel habits • Habits: Smoking/ Pan chewing/ Alcohol intake • Hygiene/Socio-economic Status • Exposure to dusty atmosphere or chemical irritants or fumes OTHERS • Menstrual History. • Socioeconomic history. • Immunization history – in case of a child. • Children: examiner should be told about the person from whom you have taken history, e.g. Mother in case of a child.

8. GENERAL PHYSICAL EXAMINATION Mental status-- Orientation to time, place & person Facies Pallor/ Icterus/ Cyanosis/ Clubbing/ Pedal oedema/ Generalised Lymphadenopathy Built Nourishment Vital data: Pulse SPO 2 Respiratory rate Blood pressure Temperature

9. SYSTEMIC EXAMINATION • CVS – S1, S2 heard, no audible murmurs. • RS – normal vesicular breath sounds heard, no crepts , no wheezing. • CNS - Higher mental functions, Motor functions, Sensory functions - normal. • Cranial nerves – facial nerve, olfactory, hypoglossal, vagus , glossopharyngeal, trigeminal, auditory nerve. • Per Abdomen- soft, non tender, no organomegaly.

10. LOCAL EXAMINATION EXAMINATION OF PINNA EXAMINATIO N OF POST-AURICULAR REGION EXAMINATION OF EAC WITH SPECULUM WITHOUT SPECULUM OTOSCOPIC/ OTO-ENDOSCOPIC EUM EXAMINATION OF TYMPANIC MEMBRANE

11. EXAMINATION OF PINNA

12. EXAMINATION OF TYMPANIC MEMBRANE

13. EXAMINATION OF TYMPANIC MEMBRANE

14. EXAMINATION OF MIDDLE EAR

15. EXAMINATION OF EUSTACHIAN TUBE PATENCY

16. EXAMINATION OF EUSTACHIAN TUBE PATENCY

17. EXAMINATION OF EUSTACHIAN TUBE PATENCY

18. EXAMINATION OF EUSTACHIAN TUBE PATENCY

19. EXAMINATION OF EUSTACHIAN TUBE PATENCY

20. EXAMINATION OF EUSTACHIAN TUBE PATENCY

21. TUNING FORK TESTS

22. TUNING FORK TESTS

23. TUNING FORK TESTS

24. TUNING FORK TESTS

25. TUNING FORK TESTS

26. FISTULA TEST

27. EXAMINATION OF FACIAL NERVE

28. EXAMINATION OF FACIAL NERVE

29. PROVISIONAL DIAGNOSIS This is a case of COM with central perforation with moderate conductive hearing loss with no mastoiditis and no facial nerve palsy/ any other complications……☺☺☺