ENT PROFORMAS

Identification Data:

Name
Age
Sex
Address
Occupation
Informant (for children)

Chief Complaints and History of Present Illness:

Dealt separately case wise

Past History:

History of similar complaints

History of Chronic illnesses, Allergies and Blood transfusions
Past Medical History
Past Surgical History

Treatment History:

Previous
Present

Family History:

History of similar complaints

History of Chronic Illnesses and Allergies

Personal History:

Diet
Appetite
Sleep
Bowel and Bladder
Addictions
Menstrual History

General Examination:

CCC, built, nourishment, etc.

PICCKLE
Vitals:

Temperature
Pulse
BP
RR

Local Examination:

USING ILLUMINATION FROM BULL’S EYE LAMP AND HEAD MIRROR,

Firstly inspect the head and neck for any facial asymmetry, any swellings, scars, ulcers, proptosis,
frog face deformity, any adenoid facies, any engorged veins etc.

EAR:

Right Ear Left Ear

INSPECTION:

Pinna: position, size and skin over it.

Pre, supra, post and infra auricular areas: any anomalies- preauricular
sinus, Battle sign, Gresinger sign, parotid swelling, mastoid swelling
EAC: On pulling the pinna backwards, upwards and outwards/
inferiorly in children- patent/not – any wax, any discharge, any fungal
mass, etc.
Tympanic Membrane: With/Without Toynbee aural speculum –
intact/ perforation – central or marginal with type (small, medium,
large, subtotal, total) or healed, dry or discharging (Reservoir sign) ,
color-pearly grey, normal position or retracted or bulging, cone of light
seen/not

PALPATION:

Tragus sign, Fistula test, Mastoid tenderness,

Fluctuation, three finger test, Head impulse test etc.

Using Gardiner Browne’s tuning fork (512 Hz),

1) Rinne’s Test – positive/negative

2) Weber’s Test: / /

3) ABC: Normal/short
NOSE and PNS:

Right Left Side

side

INSPECTION:

External Nose: Nasal pyramid, any deformity etc.

Vestibule: any vestibulitis
Nasal cavity: On lifting the tip of the nose- any caudal dislocation or
deviation, condition of the nasal mucosa, any discharge, any DNS or
spur.

1) Cold Spatula Test – using cold Lack’s tongue depressor checked

for decreased fogging due to nasal obstruction
2) Anterior Rhinoscopy: Using Thudicum nasal speculum, observe
the turbinates for any atrophy/hypertrophy/congestion,
mucosal congestion, any discharge from meatuses, DNS,
synechiae, polyp or mass.
3) Probing: Probing of mass done- check mobility, sensitivity,
bleeding, and consistency. Able to go around mass or not.
4) Posterior Rhinoscopy: Using warmed St. Claire Thompson
mirror and Lac’s tongue depressor look for the posterior end of
turbinates and any polyp.

PALPATION:

External nose palpated to check its structural framework. Test for

tenderness of sinusitis above the medial canthus of eye, posterior to
root of nose on medial wall of orbit, canine fossa.

Cottle’s Test, Transillumination test, Postural test etc.

THROAT :

Using Lack’s tongue depressor,

On Inspection:

Lips – for any cheilitis, stomatitis, herpes infection, any pigmentation

Mucosa of vestibule - any pallor or aphthous ulcers.
Gingiva – any signs of gingivitis
Teeth – any stains of tobacco chewing, caries etc.
Buccal Mucosa – any congestion or aphthous ulcers, or pallor, leukoplakia, erythroplakia.
Tongue- dorsum: tip, margins – any pigmentation or fissures on tongue, change in color or
texture, signs of glossitis, etc
ventral surface – any tongue tie, etc.
 Floor of oral cavity – any ranula, any retention cyst, or signs of submandibular sialadenitis
Hard palate – high arched or normal, any fibrosis.
Soft palate – surface congested or normal
Uvula – congested/ moving equally on making sound or not
Anterior pillars, Tonsillar fossa, Posterior pillar – any cresentic congestion, enlargement of tonsils,
Ervin Moore sign
Posterior pharyngeal wall – any pharyngitis due to postnasal drip or any membranes

Using warmed mirror Indirect Laryngoscopy is done, checking for the movement of vocal cords
and any growths or masses, any palsy etc.

On Palpation:

Any tenderness, local rise of temperature of neck, any swellings

Any lymphadenopathy – Jugulodigastric gland etc.
Laryngeal crepitus/ Bocca’s sign

Systemic Examination:

CNS
Higher functions, cranial nerves, sensory and motor

CVS
Heart sounds, Murmurs

Respiratory
Bilateral Air Entry, Type of Breath sounds

GIT
Palpation of Abdomen

Provisional Diagnosis:

Dealt separately case wise

1) CHRONIC SUPPURATIVE OTITIS MEDIA (CSOM)

Chief Complaints:

Mention chief complaints in patient’s own words in chronological order with duration.

Common:
Discharge from ear
Impairment in hearing
Pain in ear
Itching/Blocked sensation in ear

Rare and due to complications:

Ringing sensation in ear
Dizziness
Feeling of fullness in ear
Swelling in mastoid/zygomatic region, etc.
Fever
Headache
Stiffness of neck
Inability to close eyelids
Facial asymmetry
Impairment of vision

History of Present Illness:

Apparently asymptomatic ____ time ago and then developed….

Ask about each complaint, its onset, duration, progression, aggravating, relieving factors, and
effect on taking medication.

For discharge in addition ask color, amount, smell, type, consistency and any associated
condition.

For impairment in hearing in addition ask if its uni or bilateral, if fluctuating, if autophony present,
etc.

For pain in ear in addition ask about site, nature of pain, any radiation, any relevant history
suggesting it’s referred, and any associations.

For ringing sensation in addition ask type and nature.

For dizziness/vertigo ask about any loss of consciousness.

For fever ask about any evening rise, if associated with chills and rigors or not, etc.

Ask about any recent ASOM, URTI and other focal infections etc.
 Elicit any relevant positive and negative history to the complaints.

Provisional Diagnosis:

*Case Summary*and provisional diagnosis is: Chronic Suppurative Otitis Media

OF Right /Left /Both ear(s)
AND Tubotympanic/Atticoantral type
IN Active/ Quiescent/ Inactive/ Healed stage
WITH/WITHOUT Conductive deafness
WITH/WITHOUT Complications like _______________

2) SINONASAL POLYPOSIS (SNP)

Chief Complaints:

Mention chief complaints in patient’s own words in chronological order with duration.

Nasal obstruction
Nasal discharge
Bleeding through nose
Hawking sensation
Headache
Facial heaviness
Swelling or broadening of nose
Disturbance of smell
Snoring or sleep apnea
Change in tone of voice
Disturbance of taste

History of Present Illness:

Apparently asymptomatic ____ time ago and then developed….

Ask about each complaint, its onset, duration, progression, aggravating, relieving factors, and
effect on taking medication.

For nasal obstruction ask about laterality, if alternating between two sides, more during
inspiration or expiration, if associated with taking topical drops.

For discharge in addition ask color, amount, smell, type, consistency and any associated
condition.

For sneezing asked if associated with certain surroundings, and if a lot of sneezes in short
duration.

For Headache ask about laterality, if coming in bouts or continuous or diurnal variations etc.

Elicit any relevant positive and negative history to the complaints.

Provisional Diagnosis:

*Case Summary*and provisional diagnosis is: Unilateral/ Bilateral Sinonasal Polyposis

Possibly Antrochoanal/ Ethmoidal polyp,

WITH/WITHOUT DNS towards right/ left side and caudal dislocation towards right/left side
WITH/WITHOUT Sinusitis
WITH/WITHOUT complications like ______________

3) DEVIATED NASAL SEPTUM (DNS)

Chief Complaints:

Mention chief complaints in patient’s own words in chronological order with duration.

Nasal obstruction
Nasal discharge
Bleeding through nose
Hawking sensation
Headache
Facial heaviness
Disturbance of smell
Snoring or sleep apnea
Change in tone of voice
Disturbance of taste

History of Present Illness:

Apparently asymptomatic ____ time ago and then developed….

Ask about each complaint, its onset, duration, progression, aggravating, relieving factors, and
effect on taking medication.

For nasal obstruction ask about laterality, if alternating between two sides, more during
inspiration or expiration, if associated with taking topical drops.

For discharge in addition ask color, amount, smell, type, consistency and any associated
condition.

For sneezing asked if associated with certain surroundings, and if a lot of sneezes in short
duration.

For Headache ask about laterality, if coming in bouts or continuous or diurnal variations etc.

Elicit any relevant positive and negative history to the complaints.

Provisional Diagnosis:

*Case Summary*and provisional diagnosis is: Deviated Nasal Septum with Caudal
Dislocation/Deviation to Left/Right side and Spur towards the Right/Left side.

WITH/WITHOUT Sinusitis
WITH/WITHOUT Complications of sinusitis like ______________

4) CHRONIC TONSILLITIS/ADENOTONSILLITIS

Chief Complaints:

Mention chief complaints in patient’s own words in chronological order with duration.

Painful swallowing
Difficulty in swallowing
Cough
Bad breath
Thick speech
Sleep apnea
Hawking sensation

History of Present Illness:

Apparently asymptomatic ____ time ago and then developed….

Ask about each complaint, its onset, duration, progression, aggravating, relieving factors, and
effect on taking medication.

Ask for recurrent sore throats, diphtheria infection or improper immunizations, any symptoms of
suggestive of adenoiditis, hot potato voice suggesting quinsy.

Elicit any relevant positive and negative history to the complaints.

Provisional Diagnosis:

*Case Summary*and provisional diagnosis is: Acute exacerbation of Chronic Tonsillitis of

Grade ___, with/without Adenoiditis, with/without complications like __________.