history taking & examination in ent
Post on 21-Aug-2015
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HISTORY TAKING
• Name• Age• Sex• Religion• Occupation• Address
• 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).
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.
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 2nd chief complaint and like wise.
• Then negative history of overall disease picture.
PAST HISTORY
• 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
• Duration
• Onset
PERSONAL HISTORY
• Diet/Sleep/appetite
• Micturation / 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.
GENERAL PHYSICAL EXAMINATION
• Built• Nourishment• Orientation to time, place & person• Vital data:
• Pulse• Respiratory rate• Blood pressure• Temperature• Pallor/Icterus/Cyanosis/Clubbing/Pedal oedema/
Generalised Lymphadenopathy
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, gloss pharyngeal, trigeminal, auditory nerve.
• Per Abdomen- soft, non tender, no organomegaly.
EXAMINATION OF THE EAR
Right and left ear
• Pre auricular region• Pinna• Post auricular region• External auditory canal• Tympanic membrane• Fistula test• Mastoid tenderness• Facial nerve
• Tunning fork tests –
• Rinne’s
• Weber’s
• Air bone conduction
EAR
• Pinna – Shape, Size, Position.
• Post aural – Swelling, Scar, 3 point tenderness test, Battle’s sign, Griesinger’s sign.
• Pre auricular area – Sinus, Swelling, Cyst, Accessory tragus, Lymph nodes.
• External Auditory Canal – upwards, backwards & outwards.
• Without speculum and with speculum. • Examine- roof, floor, anterior & posterior wall.
• Wax, Pus, Foreign body, Granulation, Fruncle, Osteoma, Laceration, Stenosis, Atresia.
EAR• Tympanic Membrane – Describe and identify normal anatomical
landmarks-
• Colour, cone of light, • 4 quadrants, umbo, • Handle of malleus, • Lateral process of malleus, • Anterior & posterior malleolar folds, • Pars tensa, • Pars flaccida, • Bony annulus, • Incudostapedial joint.
EAR
• Colour –
• Pink (otosclerosis), • Rising Sun (glomus jugular) , • Red (acute otitis media, myringitis, baro-otitis media), • Bluish (blood accumulation).
• Cone of light – ET block, Atelectasis, serous otitis media.
• Mobility – Siegalization and Valsalva maneuver.
EAR
• Pars tensa - Retraction, Granulation, Blebs, Sclerotic patches or perforation.
• Perforation – Type, Margins, Location, Size, Shape, Edge, Residual drum, Structures seen through perforation, Granulation, Postero-Superior retraction with cholesteatoma, Polyps, & Tympano-Sclerotic Patches.
• Pars Flaccida – Attic or Sharpnell’s membrane.
• Central perforation is ‘SAFE’ while Marginal/attic perforation is usually ‘UNSAFE’.
EXAMINATION OF THE NOSE
Examination of external nose {skin and
osteocartilaginous framework}
• Inflammation • Scars • Sinus • Swelling • Neoplasm • Deformity
Examination of vestibule
• Furuncle • Fissure • Crusting • Dislocated caudal end of
the septum • Tumours
EXAMINATION OF THE NOSE
Anterior Rhinoscopy
• Nasal passage • Septum • Floor of nose • Lateral wall• Nasal mucosa• Turbinate hypertrophy• Shape of turbinate
Posterior Rhinoscopy
• Choana • Posterior ends of inferior
turbinates • Posterior end of septum• Discharge• Openings of the Eustachian tubes • Posterior end of middle turbinate• Fossae of Rosenmuller
EXAMINATION OF THE NOSE
Functional Examination of Nose
• Cold Spatula test
• Cotton-wool test
• Sense of smell• Cottle’s test
Paranasal sinus tenderness
• Maxillary• Frontal• Ethmoidal
ORAL CAVITY & OROPHARYNX
INSPECTION:
• Lips• Teeth• Gums• Buccal mucosa• Anterior 2/3 of tongue• Floor of the mouth• Hard palate
ORAL CAVITY & OROPHARYNX
• Soft palate• Oro-antral fistula• Anterior pillar• Tonsil• Posterior pillar• Posterior
pharyngeal wall
ORAL CAVITY & OROPHARYNX
• Tongue :
• Anterior 2/3rd , & Posterior 1/3rd.• Size, Appearance, Swelling, Ulcer, Mobility, Dorsum and Floor of
Tongue.
• Tonsils:
• Gr. 1 – medial surface of tonsil hidden behind anterior pillar.• Gr. 2 – medial surface of tonsil just at level of anterior pillar.• Gr. 3 – size in between Gr. 2 and Gr. 3• Gr. 4 – tonsil touching each other ( kissing tonsils).
ORAL CAVITY & OROPHARYNX
• Tonsil 0: Tonsils fit within tonsillar fossa
• Tonsil 1+: Tonsils <25% of space between pillars
• Tonsil 2+: Tonsils <50% of space between pillars
• Tonsil 3+: Tonsils <75% of space between pillars
• Tonsil 4+: Tonsils >75% of space between pillars
ORAL CAVITY & OROPHARYNX
• PALPATION :
• Tongue• Buccal mucosa• Floor of mouth• Tonsils and its bed.• Base of tongue.• Swelling in oral cavity.
EXAMINATION OF LARYNX
• Redness of skin (abscess, perichondritis)
• Bulge or swelling (extension of growth or enlarged lymph nodes)
• Widening of larynx (growth of pyriform fossa)
• Surgical emphysema (accidental or surgical trauma)
• Palpate the hyoid bone, thyroid cartilage, thyroid notch, cricoid cartilage, and the tracheal rings.
• Movements of larynx (laryngeal crepitus).
STRUCTURES SEEN ON INDIRECT LARYNGOSCOPY
• Larynx - Epiglottis, aryepiglottic folds, arytenoids, cuneiform and corniculate cartilages, ventricular bands, ventricles, true cords, anterior commissure, posterior commissure, subglottis and rings of trachea.
• Laryngopharynx - Both pyriform fossae, postcricoid region, posterior wall of laryngopharynx.
• Oropharynx - Base of tongue, lingual tonsils, valleculae, medial and lateral glossoepiglottic folds.
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