HISTORY TAKING ENT Ear, Nose & throat ward indoor patients Registration No. 54/59 Bed 39 ___Date of Admission_%-|2-20 _ Name. tera Bibi Som/Daughter/wito of_Ali Ahmed. Age oS. yxs Sex_ Female. occupation Howse wife Address Allahbad Colony, Mylkan « Presenting complaints iffy n_swattawing. \ k \ Ch History of present illness: hod Dh om font 2yrs wa in sua stake fh alth or 3} for soli idle ak 8 Joppa in_back 6. ‘ 2_cAlco sao doles in __swallawing te ob foo. Pt oteo bag acfbiculhy LA ows, drawing saliva —too Past History_! ¢he cee a of HINS pM. No pack history oP iE™ Na “pact thiskeoy af ‘vauma and blood bansfaxion. Family History No family he bory of HTN 4 Dwi. i Social History Nao-addict» Non-tmakerGeneral Physical Examination General appearance jl Logeing eight bs ka Anemia eee Jaundice Ab Cyanosis _ fb Blood pressure 76] Boom Pulse §0/oun Temp Age Lymph Nodes oot ; Thyroid Gland_Novmal Clubbing Ab _ Respiratory Rate 24min Cardiovascular System: Palse is sO fain BP is S/Smmetitg - Bath cheavt counds are normal No mutmur<- No Central Nervous System: Pict fully ansibis, well cele i ip Line Apa Yespixalion: ob cone and of Ui shape. Bowel son 3- “Sper min, Endocrine System: endocrine fonctions are ‘ppymal-Nos (1) External Nose examination or Nose Io 4 Normal Any swelling, scar mark, and skin lesion Absent Palpation Tenderness over maxillary sinuses __ fb 1109 Tenderness over frontal sinus Ab Nasal bone crepitus fb For any other lesion found on inspection Wb ~ amis t Examination of internal Nose (a) Vestibule Boil fb Cracks | “Ab etc! re (b) Anterior Rhinoscopy Medial wall of nose (septum) Normal. a Lateral wall of Nose Inferior and middle Turbinates Noymal. Inferior and Middle Meastuses__—s NO Yn. | « Floor Normal. “a i(a) Patency of Nose Right Nostril Left Nostril Patent Wy —“ Patrial blockage Xx — Complete BlofRage (b) Mass Ch (d) Foreign Body (c) Adenoids (d) Post Nasal Discharge Se colour _ (e) Any Mass fbMOUTH Lips___ Normal check Normal Condition of teeth and Gums Normal . So a Condition of Tongue Normal Floor of Mouth Normal: Palate Color__Novmal Movements Normal Sensations Nosmal. Tonsils Condition of Anterior ayd posterior fa cial pillars Normal - Hypertrophy | flo: ll ppearance Nov ma. Ulceration Ad Mass Crypts_Notmal - Membrance _Naymal, Posterior PRaryngeal wall Any bulge Bb. Any Ulcer hb» Condition of lymphoid tissue N oyna s Jagulo- digastric lymph Nodes __Not-€nlawgedls ___—(a) External examination Inspection Normal! y ; ZL Act of Deglutition Noma) . Palpation Laryngeal cartilages( \.___* Nofima Laryngeal craptius _| Cervical lymph node: (b) Internal examination by indire (1) Base of tongue _| mT (2) Valleculae i (a) Colour Ucler (9) Subglottic Area (10) Pyriform Foksae |EARS (1) Inspection Pinna Nima) Mastoid_Norimal__Tragus_ Nownal - _ Post Aural Sulcus Noymal- (2) Palpation a: (a) Confirm findings of inspection as i (b) Tenderness over Mastoid Aocen: (3) External Auditory Meatus Discharge fb : Colowx as Amount _— Smell — Mass _FB_ fb etc__ — (a) Colour ld) Positigh (d) Perforation j Lb is i a Valsalva - Man¢uver (For pA fenay of Eustaghian Tube) N (5) Tuning Fork { : : Rinne’s Test 4 ee — Weber’s Test = Ee ABC Test _ ce Schwabach’s Test = a Bing Test , ee Gelle’s Test cca(© VESTIBULAR FUNCTION TESTS B (a) Caloric Test (b) Nystagmus Ab (c) Past pointing (d) Falling Tendency \ (e) Rotation Test (f) Galvanic Test (g) Fistula Test (7) Facial Nerve Function Norma + 1 | (8) Posterior Rhinoscopy : ole. (9) Lymph nodes (upper deep cervical) (10) X-ray Mastoid comparative Differential Diagnosis Diagnosis Say. Cell carunoma of thyvat)INVESTIGATIONS General 1. Complete Blood Examination wemal . 2. Complete Urine Examination Normal ' 3. X-ray Chest. . Noymea 4. Bleeding Time 1 min 5. Clotting Time lomth . 6. Australia Antigen ~ve 7. Anti - HCV -ve. Specific investigations (Ear, Nose, Throat) 1. X-Ray PNS.. . 2. X-Ray Nasephari, Lateral view. Vv 3. X-Ray Neck - Lateral View (STV) ~~ 4. X-Ray Nasal Bone - Lateral View 5: \xRay Mastoid Comparative 6. X-Ray Base of Skull. 7, X-Ray Barium Swallow - AP view - Lateral view. 8. Pure Tone 3. X-ray Chest 4. Bleeding-Time 5. Clotting Time 6. Australia Antigen 7. Anti- HCVDate: art Anesthesia Surgeon Anesthetist Operation Not canied ovt se Operative = ‘i / es Gfve. peeper Qaluice. ae \ Post - Operative Cait Treatment Br = Chemotherapy) 4HISTORY TAKING ENT Ear, Nose & throat ward indoor patients Registration No,_|72__ Bed $Date of Admission 12-|2-20°_ Name_Armina Bibi Son/Daugfiter/wife of _1 mad Age 46 NWS: Sex fermale . eS Howse wafe. Address Nw a4gara a. Presenting complaints ee We a ffi ts Paciinty— Fen bon Hath pavenk_ateabie heal Ne ancily hice of DML HTN, TB Social History Non-addict , mansmekey . Howe nike mi |Shape. cenballNose 1) External Nose examination or Nose —Noymctl a Any swelling, scar mark, and skin lesion -NO swelling. Bittlaenaat puecenl No eieén fesian . alpation enderness over maxillary sinuses__ Ib) saleolesisiemnean nderness over frontal sinus fi asal bone crepitus Ab For any other lesion found on inspection Nil). — 2) Examination of internal Nose Vestibule : 7 ee Boil Not pregntl Grkéks 20 ie aPealtete OF ered t (b) Anterior Rhinoscopy ri 1oirta}204F (2) Lateral wall of Nose 2 | ‘yioviaieog Yo nditibnoD (s) Inferior and middle Turbinates __ Noymak* Inferior and Middle Meastuses Floor Normal.——— (a) Patency of Nose Right Nostril Left Nostril g! v Patent —— Patrial blockage = _____&_ —___—_ Complete Blockage ___. st (b)Mass___ fib ©) Polyp (d) Foreign Body Ab (e) Anterior Nasal Discharge Amount __— Colour__— __ Consitency (THREE TESTS TO CONFIRM LESIONS IN THE NOSE (i (a) Nasal blow test_ Normal _(b) Probe Test_N onmal (c) Vacoconstrictor spray test (c) Posterior Rhinoscopy (a) Condition of posterior Nares (b) Eustachian Tube Vomal » Orifices_ Nownal (0) Adenoids Not énlereedd o (d) Post Nasal Discharge Ab colour (e) Any Mass db, AMOUTH Lips Normal . check Norma . Condition of teeth and Gums Nomatl . Condition of Tongue Now f Floor of Mouth Nanaclt Palate Color Normal. Movements’ Nenmaol Sensations Noymad . Tonsils Condition of Anterior,and posterior faucial pillars Noymad Hypertrophy fb Appearance Noymak » Ulceration pb Ae, Poss Rb ___Membrance Bb Crypts fro. : : Colour Derm el Posterior Pharyngeal wall Any bulge fb Any Uleer fe . Condition of lymphoid tissue Normal » Jagulo- digastric lymph Nodes Not en arged \Act of Deglutition Difficulty —Lacudall at nie o-sing Palpation Laryngeal cartilages i Cervical lymph nodes —Net potable —— Upper falpaloie | - VT memovom Middle HIN. Family History _- No Withowy a £ WL Ty) Hin: Social History Non-cmakew, None adldict +CO —— General Physical Examination G Anemia General appearance {ll weight 6244 63M ; oa ressure (20 Jaundice No» Cyanosis_N®___ pT P os Pulse_ i /acTemp WF Ly Lymph Nodes x Thyroid Gland Notmat Clubbing Alo Respiratory I Rate <, roe Cardiovascular System: Pulse erie £P ic 12° 40-rom 4 Both i ie Cound . Respiratory System: Resp wake is Oe fos Sore tthe tomatoe, Central Nervous System: -—— fic filly — “epaa um eee Tal alo (Ole es time fae nace - (yanlal neve desk & mule _ power = Gastro Intestinal Tract: ~oberadian are -A.o¢ mal. Endocrine System:" =). _ AM endocrine Goi i morvmal+Tendern Nasal bone erepitus For any other lesi rd lesion fo(a) Patency of Nose Right Nostril Patent Unkle Ae Patrial blockage us Complete Blockage x (©) Mass Ab __ (6) Polyp (d) Foreign Body (e) Anterior Nasal Discharge Amount — Colour__— ___ Consitency _ (THREE TESTS TO CONFIRM LESIONS IN THE a aMOUTH Lips Noval - check wail: condition of teeth and Gums Namal! Condition of Tongue Normal: Floor of Mouth _Notmah,- Palate : Nd sep) Fold Color _Notmal: Movements _Notmal- Sensations Normal Tonsils Condition of Anterior and posterior faucial pillars _Novmel - ai Hypertrophy owaid Appearance Normal - Ulceration fre 5 Mass fe Membrance _N Crypts N Colour N ( Posterior Pharyngeal wall Any bulge fb ~__ Any Ulcer tb Noval + ; Condition of lymphoid tissue Jagulo- digastric lymph Nodes ple oe(a) External examination ‘ a Inspection Novmat + 2m Dis MSO) Tore Act of Deglutition Palpation Nom ak + SHaBE Laryngeal cartilages Laryngeal craptius Cervical lymph nodes —Not palpable __ Upper F Middle Benee _. Incricyd atnemievenyl ks (b) Internal examination by indirect laryngos (2) Valleculae (4) Aryepiglottic folds (5) ArytenoidsEARS (1) Inspection Pinna Normal __Mastoid_Nowmna Tragus_Nomal. Post Aural Sulcus Notmal: i 2 Palpation (a) Confirm findings of cer iat efi (b) Tenderness over Mastoid -fb— oe (3) External Auditory Meatus Discharge _ fb — Colour Smell as N “hp ao FB) fb etc : | | Nee (5) Tuning Fork Tests a. Maey ’ | Rinne’s Test _ a Weber’s Test ee ee at ABC Test a ‘ a Schwabach’s Test ail = — Bing Test sil | Gelle’s Test ies —¥ (6) VESTIBULAR FUNCTION TESTS (a) Caloric ee er (b) Nystagmus __Ab__(e) Past oo (@) Falling Tendency a ee (©) Rotation Test Maal —____ (8) Galvanic Test N (g) Fistula Test Nov Oue (7) Facial Nerve Function NoyMal- (8) Posterior Rhinoscopy Notma) - ee 3 (9) Lymph nodes (upper deep cervical) (10) X-ray Mastoid comparative Next Differential Diagnosis : CSOM | DiagnosisM General L. . Clotting Time INVESTIGATIONS Complete Blood Examination Normal 2. Complete Urine Examination Normal 3. X-ray Chest | Novmat: 4, 5. 6 Bleeding Time — Smin - Brin: . Australia Antigen = Negative - 7. i Anti - HCV Neseddive : Specific investigations (Ear, Nose, Throat) I: a nAU Pe WB WARD H PWD X-Ray PNS. . X-Ray Nasopharnx - Lateral view. . X-Ray Neck - Lateral View (STV) . X-Ray Nasal Bone - Lateral View . X-Ray Mastoid Comparative ~~ . X-Ray Base of Skull. X-Ray Barium Swallow - AP view - Lateral view. . Pure Tone o . X-ray Chest . Bleeding Time . Clotting Time . Australia Antigen . Anti - HCVAnesthesia__© : Date: _ oe Anesthetist Surgeon — i Operation Not” Operative Notes TreatmentHISTORY TAKING ENT Ear, Nose & throat ward indoor patients : | RegistrationNo. 440 Bed 25 -22__Date of Admission 21- t2.— Name__S abiy fh med Son/Daughter/wife eee. Age & 7S Sex M occupation sh dent - Address Mulkan « Presenting complaints Rerinvenk sone tyroak ~ 3ync. Movth beathing = Bniys “Snoming = @yys- a ee History of present illness: neath N% ago wohen' he d Yeuurren ee ore davpak je Y 3-7 gpifode in a year Mae i alsa has hnictory of moutts treating: Past History No past laistory _of- 0M HTN, TR - No operakion aor pas to hospital « Family History No family lnishery af DML HTN TB. Social History m= addict , Pt bebengs +2 —avtddie Clay,Ganeral Physical Examiltation Anemia — 0b 10iiny appearance A! Weight oO ica cues Blood pressure 10 qin Lymph Nodes —Not Gener Jaundice yyy Cyanosis Pulse @) jmaunTemp_! \eoF Resp aoe Rate Thyroid Gland __pyoymat_ Clubbing tb — Cardiovascular System: Bots heart Samds_ave noire! nD muynawy _ay_added sounds. Respiratory System: _ ae re alalnietiasc readNose External Nose examination or Nose Norma hy swelling, sear mark, and skin lesion Ro- Ipation ynderness Over maxillary sinuses Db A201 iderness over frontal sinus _ _ fb sal bone crepitus 707 asain, nr any other lesion found on inspection —— fp. ‘dbo agis107 (b) ) Examination of internal Nose ) Vestibule 2. 7 oil Pe Vi Gtacksl 2 ) Anterior ia ed Slat yqoozonidh toiisi2o' ateral wall of Nose es to noBibnoD (s) ois 1ogoieog te nolibnoD (s) inferior and middle Turbinates ——N rce ZT gait _ luT nsidasies nferior and Middle Meastuses Bown cs wolos seiscioe2iC] Ises' »4 (b) loor __ quoloo eee Q a Noel(a) Pateney of Nose Right Nostril Left Nostri] Patent c a i “~ Patrial blockage ‘ ss R x Complete Blockage (b) Mass te (©) Polyp_fla See (d) Foreign Body pe SSS (e) Anterior Nasal Discharge fie ae Amount nt Colour__— __ Consitency aa (THREE TESTS TO CONFIRM LESIONS IN THE NOSE (a) Nasal blow test Novinat- (b) Probe Test Nsvrie (c) Vacoconstrictor spray test Neovmet_ (c) Posterior Rhinoscopy (a) Condition of posterior Nares oeNotmad - ee (6) Eustachian Tube Ntn_eA Orifices Novmal- (0) Adenoids —SSa8 si: Ean neemie 7 (d) Post Nasal Discharge fb’ colour me — (e) Any Mass fro —_—_eMOUTH Lips Normal check Neimot « Condition of teeth and Gums 0a nme Condition of Tongue Pores Floor of Mouth sninall a Palate sc : Color Novinat Movements Nosmok __ Sensations Nomes » Tonsils Condition of Anterior and posterior faucial pillars_ Normal _- Hypertrophy fo” Appearance Qe- Ulceration Plo Mass fb Membrance Naval . Crypts Notmael «Colour Novmal - Posterior Pharyngeal wall Any bulge Pb Any Ulcer pro: Condition of lymphoid tissue Noymak - Jagulo- digastric lymph Nodes ——Not_polpalele