Final Diagnosis: LEFT CHRONIC OTITIS MEDIA MUCOSAL TYPE

procedure done : LEFT TYMPANOPLASTY UNDER GA

Chief complaints:

C/O left ear discharge for 1 year

c/o left ear pain ( intermittent)for 1 year

c/o hard of hearing for 1 year

History of present illness:

The patient was apparently normal 1 year back, following which she complaints
of left ear discharge on and off , aggrevated on upper respiratory infection and relieved on
medication

C/o left ear pain on and off for 1 year

History of hard of hearing

Past medical history:

Not a known case of systemic hypertension, diabetes mellitus, bronchial asthma , epilepsy,
tuberculosis

Past surgical history:

No significant Past surgical history

Personal History:

mixed diet

normal bowel and bladder habits

Normal regular menstrual cycle

Examination:

General condition:

Gc fair

conscious ,oriented and afebrile

No pallor, no pedal edema, not icteric, no cyanosis, no clubbing, no generalized

lymphadenopathy

Vitals stable

Systemic examination:

CVS: S1 and S2 heard

RS: Normal vesicular breath sounds heard

Local examination of bilateral post auricular region: Normal
Ear:

RIGHT LEFT

PINNA Normal Normal

EAC Normal Normal

Large central perforation

Tympanic membrane NORMAL
present

Mild conductive hearing

PTA mild conductive hearing loss
loss

Facial nerve clinically intact clinically intact

Nose:

RIGHT LEFT

Septum Normal Normal

DNE findings Normal Normal

Nasopharynx normal normal

Throat:

Tonsil grade and condition normal

Oral cavity normal

Oropharynx normal

Larynx normal

Hypopharynx normal

Neck: normal

Investigations: Echo: ASD with ostium secundum with left to right shunt ( size 2cm)

Right atrium and right ventricle are dilated

 Normal left ventricular function, EF - 55%, TR - Trivial, TR PG : 25+5mm Hg

mild PHT, no clot , no PE

Course of stay: A 35 years female patient presented with above complaints and admitted in ENT ward
with diagnosis bilateral chronic otitis media mucosal type initial investigation were done,Ecg showed T
wave changes in lead 3 and AVF, so cardiologist opinion was sought and patient underwent left
tympanoplasty under GA.post op period was uneventful, Patient improved symptomatically. Hence
discharged with following advice.

Treatment given in hospital:

INJ.CEFOTAXIME 1G IV BD

INJ.PANTOPRAZOLE 40MG IV OD

INJ. DICLOFENAC 50MG IM SOS

TAB. LEVOCETRIZINE 5MG HS

OPERATIVE NOTES:

Under general anesthesia, patient in supine position, William wilde post auricular incision
given,and TFG harvested, posterior meatotomy done and margins of cp freshened ,tympanomeatal flap
elevated and TFG placed by underlay techniques, middle ear and EAC packed with gel foam, haemostasis
attained , mastoid dressing done, patient tolerated the procedure well

Medication advised at discharge:

Sl
Formulation Drug Dose Frequency Days Before/After food
No

1 tablet CEFIXIME 200mg 1-0-1 5 days after food

2 tablet Paracetamol 650MG 1-1-1 5 days after food

3 Tablet Pantoprazole 40mg 1-0-0 7 days Before food

4 Tablet LEVOCETRIZINE 5mg 0-0-1 7 days After food

5 Capsule Abound plus 0-1-0 7 days After food

review after 5 days in ent opd for suture removal

Precautions and danger signs

Nose
Avoid head bath, hair oil application Avoid lifting heavy weight
Review in Emergency/ OPD in case of giddiness, facial asymmetry, ear discharge

Signature & Seal of Treating Consultant

NOTE: In case of Emergency; Please Contact: 044 27528528, Toll Free No: 1800 599 0999.
அவசர உதவிக்கு தொடர்புகொள்ள வேண்டிய எண் : 044 2752 8528,
கட்டணமில்லா தொலைபேசி எண் : 1800 599 0999