history taking in otorhinolarygology patient

history taking

1. HISTORY TAKING OTORHINOLARYNGOLOGY Dr MOHAMMAD SHAKEEL PROFESSOR DEPARTMENT OF ENT

2. LEARNING OBJECTIVES - Develop a systematic approach to interviewing and history taking of the ENT patient - Gain understanding of all components of history taking - Learn about what are the key points in Otorhinolaryngology for timely referral to the specialist

3. HISTORY TAKING

4. HISTORY Chief complaint: Ear? Nose? Throat? Neck? HOPI : Onset, frequency, duration of COMPLAINTS Associated symptoms What has the patient already tried ? Evaluation of any associated systemic disease Previous work-up, testing, imaging, or interventions What has already been done or tried for this?

5. HISTORY Past Medical History: Allergies? Asthma? Neurologic or rheumatologic disorders? Past Surgical History: Head and neck procedures? Allergies- Aspirin Sensitivity? Addiction/Social History - Smoker? Alcohol use? Family History- Does this run in the patient’s family?

6. Review of Systems:Chief complaint: Ear? Nose? Throat? Neck? Ear: tinnitus/ vertigo/ hearing loss/ otalgia / otorrhea Nose: congestion/ rhinorrhea/ epistaxis/ decreased smell Throat: pain/ dysphagia/ odynophagia Larynx: hoarseness/ voice changes/ noisy breathing/ difficulty breathing / pain with speaking ( odynophonia ) Trachea: noisy or difficulty breathing Neck: lymphadenopathy/ new lumps or bumps/ pain/ swelling Face: sinus pain/ pressure/ swelling/ numbness

7. Hoarse voice for more than 3 weeks ( tumour/occupational) Foul-smelling otorrhoea ( cholesteatoma ) Unilateral foul nasal discharge in a child (foreign body) Unilateral nasal polyp/blood-stained rhinorrhoea (tumour ) Unilateral deafness (SNHL/tumour ) Persistent lump in the throat (tumour). Danger Signs in ENT History

8. All neck lumps must be referred for ENT examinatino : since, if malignant, the primary site is likely to have arisen in the : nasopharynx ; oropharynx; tonsil; tongue base; pyriform fossa; larynx; upper oesophagus.