History Taking IN ENT Theory and ENT OSCE

1 Patient profile: Name, Age, Sex, Address, DOA, DOE 2 Presenting complaints: Chronological order 3 History of Presenting complaints: Mr. / Miss came with c/o …..For …… Mnemonic DOC4OBA2 H/O EAR DISCHARGE: 1 Duration 2 Onset – Insidious/ gradually progressive/ 3 Continuous/ Intermittent (Duration, frequency, how long it last) 4 Color- Yellowish/ White/Colorless 5 Character- Mucoid /Mucoprullent/ Purulent 6 Consistency-Thick /Thin 7 Odor-Foul smelling/Not 8 Blood stain / Not 9 Amount- Scanty/ Moderate/ Profuse 10 Aggravating /Relieving factor H/O Hearing loss 1 Duration 2 Onset- Insidious/ gradually progressive/ sudden 3 Progression-static/ gradually progressive 4 Fluctuations 5 Hampering social life/ Not H/O 1 Earache 2 Ringing sensation of ear (Tinnitus) 3 Dizziness ( Vertigo) 4 Trauma to ear 5 Exposure to loud noise 6 Ototoxic drug in past …. 7 Pre/ Post auricular swelling 8 Facial asymmetric 9 Deep seated headache 10 High grade fever 11 Projectile Vomit 12 Blurring of vision 13 Abnormal body movement H/O Throat / Nasal symptom Rx History if present Past history: H/O PTB , DM , HTN , ASTHMA, Surgery in the past Family history: H/O PTB , DM , HTN , ASTHMA, H/O Ear discharge / Hearing loss in family Personal history: H/O Ear pricking habit /Not , H/O swimming /Not , Smoking /Not, Consume alcohol/Not, Bladder ,Bowel, Menstruation ,Sleep 7 Socioeconomic condition : Allergic to aspirin or other drug IN PEDIATRIC Patients you MUST MENTION Perinatal History: Maternal immunization (TORCH), Maternal infection, Drug intake /Not, Exposure to radiation /NotDelivery: Home /Hospital/Nursing home, Full term/Pre term, vaginal/ CS/ Forceps 3 Developemental: 1st social smile (6wkk), Roll over (6mts), Sits with support (3-4 mts), Sits without support (6mts), stand with support (1 yr), Stand without support ie; walk (1-1/2 yr) 4 Immunization – according to EPI BCG – At birth 1 dose (0.05ml) Intradermal (upper & outer arm) Polio – At birth, 6, 10, 14 wkk (4 dose) 2-3 drop P/O DPT- 6, 10, 14 wkk (3 dose) 0.5 ml (IM upper & outer part of mid thigh) Measles – 9 mts (1 dose) 0.5 ml (subcutaneous) TT – At first contact , 4 wkk, 6 mts , 1 yr ,1yr ,( 5 dose ) 0.5 ml (IM – upper & outer arm) 5 Physical abnormality: 6 School performance: 7 Appetite: 8 Family sibs: 9 Pets at home: HISTORY TAKING NOTES FULL ENT OSCE EXAMINATION: GENERAL EXAMINATION: APPEARANCE: Fair / ill looking Body built: Average / Emaciated, Nutrition: Cooperative / Not Oriented to time place & person / not, Pulse - BP- Respiration- Temperature- On Examination of head & neck Inspection of Pinna: Normal in shape, size, color, position, symmetric Pre / Post / Infra auricular area: No Scar, Swelling, Sinus, Fistula, Sign of inflammation On palpation: No tenderness on pressure over tragus, cymba concha, on various movement of Pinna & over the mastoid On Examination of EAC with speculum: Normal in shape & caliber No wax, Discharge, Debris, Sign of inflammation, Polyp/ granulation/fistula seen On Examination of TM RT / LT Pars Tensa – is intact / perforated in PS /PI, AS/AI quadrant & is ………. % of Pars tensa, Shape ….Margin of perforation is …….. Color: Pearly grey (normal color) / White / Pinkish / Dull lusterless * rest of the TM is …..in color+ Texture: Normal / Thick / Thin land mark: -Short process of malleolus – prominent -Anterior malleolar fold -Posterior malleolar fold -Handle of malleolus (foreshortened) -Cone of light (AI/ Distorted/ Absent) Tympanosclerotic patch / Epithelization / Retraction pocket / Granulation tissue / Air bubble / incostapedial joint (if present say where it is?) On sigelization test: Mobile/ restricted / absent mobility (Pars tensa) Describe through perforation (Describe middle ear) I can see ………..1 mucosa color *Pinkish –normal, Reddish / edematous if inflamed] 2 ET orifices, Promontory, RW, OW, and MEC filled with discharge. Pars flaccida: is normal –Pinkish / if you say destructed then perforation is there & cholesteatoma present say it where is it Outer attic wall (scutum) how it is destructed due to cholesteatoma/not. Round window Fistula test: -ve / + ve Facial nerve: all branches intact/ not. Examination of nose and PNS Telecanthus – present/absentExternal osteocartilaginous framework –NormalAbnormal – dorsum deviated/ depressed dorsum/ saddle nose etcNo swelling, scar mark, sinus, signs of inflammationNasofacial groove, alar groove, nasolabial folds – normal/ obliterated Patency test – B /L equal, reduced on one side, absent etc Examination of vestibule caudal end of septum – midline/ deviatedfloor and lateral wall- normal /abnormalno crusting/fissuring/discharge/swelling/ signs of inflammation Anterior rhinoscopySeptum – midline/ deviated: overlying mucosa – normal ( pink) or pale or congestedInferior turbinate and middle turbinate and their respective meatus and overlying mucosa - normal, pale, congestedIf covered by mass, mention which part of these two turbinates are visible.If mass presentSide – rt/ lt/ bilateralSingle/ multiplecolor – pale, pink, reddish etcShape- globular, grapelikecovering the nasal cavity completely or partially or just meatusshrink on using decongestanton probingconsistency – soft, firm , hard etcsensitive to touchbleeds on touchcould pass the probe around which part of the mass – so the probable site of origin is ……discharge if present – describe nature of discharge – mucoid/ mucopurulent/ purulent etc: mention amountIf there is no discharge or mass seen – mention about the roof and floor of the nasal cavity -Posterior rhinoscopy mention all the structures seenPosterior surface of uvula, soft palatePosterior end of the nasal septumB/L posterior end of Superior turbinate Middle turbinate Inferior turbinate seen Eustachian tube opening normalB/L Choana - freeNo discharge /mass seen -any discharge ( nature of discharge – mucoid/ mucopurulent/ purulent etc: mention amount) -any mass covering the choana Paranasal sinuses the area over the paranasal sinuses – frontal, ethmoiidal, maxillary sinuses is normalno swelling, scar marks, signs of inflammationon palpation – tenderness elicited over …../ no tenderness Examination of eyes - gross vision (diplopia,blurringof vision), epiphora, mobility of eyeball – normal Examination of neck Inspection No swelling, scar marks, visible pulsation or engorged veins Laryngeal framework is normal Palpation No local rise of temp or tenderness No lymphnodes or any other swelling palpable Laryngeal crepitus – present Trachea is central. Auscultation Examination of oral cavity Trismus : Present /not Vermilion border Upper & lower Lips – normal/cracks fissuring/any abnormality present/not Gingivolabial and gingivobuccal sulcus – normal Buccal mucosa – normal Gums and teeth – normal / any missing tooth or loosening of tooth if yes which tooth? Retromolar trigone – normal Anterior 2/3 of tongue – normal with normal mobility Floor of mouth – normal Hard palate – normal Examination of oropharynx Soft palate – normal with normal mobility B/L Anterior and posterior tonsillar pillars – normal B/L tonsils – normal / hypertrophied if so grade ? Posterior 1/3 of the tongue Posterior pharyngeal wall – normal and gag reflex present / PND present? On Indirect laryngoscopic examination Base of the tongue , B/L valeculla, Lingual & laryngeal surface of the epiglottis , B/L PE fold , AE fold, Arytenoids, FVC, Ventricles, TVC, Pyriform fossa normal /abnormal History taking of nose case Nasal obstruction- Sides,durationonsetPartial or completeProgression ? if so partial to complete ? how long has the obstruction been complete?Associatedwith loss of sense of smell?Difficulty in breathing? Mouth breathing? Snoring while sleepingFacial pain or headacheAggravated by attacks of URTI, relieved with use of medication Nasal discharge Sides, durationonsetNature, amountBlood tinged?Aggravting and relieving factors?h/o recurent sneezing, change in voice ( hyponasal voice), recurrent clearing of throat ( s/o PND)no h/o of diplopia, decreased vision, excessive lacrimationno h/o decreased hearing, rec ear ache, ear dischargeno h/o rec sorethroat, odynophasia, dysphagia, rec coughing, neck swellingsno h/o chest pain, palpitation, abdominal pain ( ruling out systemic ilness) HISTORY TAKING NOTES FULL ENT OSCE Source - Dr shiva chand shahi

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