HISTORY TAKING AND EXAMINATION OF THROAT

Name (Identity): Age:

Address:
Informant:
Reliability-
If Informant is Mother – GOOD
If Informant is Grandparents- FAIR
If Informant is Neighbour – POOR

Chief Complaints :
1.Recurrent episodes of throat pain – Duration
2.Recurrent episodes of Sore throat- Duration
3.Pain during Swallowing – Duration

History of Presenting Illness :

1,2. throat pain and sore throat –
Onset-sudden(acute)/Insidious (Chronic) , No: of episodes
/month or year
Nature- Pricking
Radiating – (to ear)
Aggravating- Cold food ,URI
Relieving- Saline gargling, medications
Whether pain or sore throat episodes are associated with
episodes of Fever
3.H/O difficulty in swallowing (Grade IV Tonsils)
Gradual /Progressive
 H/O halitosis
H/O Fever
H/O Snoring
H/O Mouth breathing
H/O Recurrent URI (For Adenoid Hypertrophy)
H/O Nasal obstruction
H/O Voice change
H/O Ear Block /Hard of Hearing → Serous Otitis Media (ET
obstruction by adenoids)
H/O Ear pain/ Ear discharge (Acute Otitis Media,ASOM ,SOM)
adenoid is septic focus
H/O Nausea ,Abdominal pain (Inflammation of Peyer’s patches)

Past History:
H/o Similar episodes in the past
H/o congenital Heart disease /BA/TB /Epilepsy
Rx history : any previous Surgeries

Personal History:
Mixed diet
Bowel and bladder habits

Family history :
Similar complaints in Siblings, etc

GENERAL EXAMINATION :
 Conscious , Oriented ( > 5 years) Alert,Awake,Active (<5 years)
Afebrile
Pallor/Icterus/cyanosis/clubbing/lymphadenopathy/edema
No features of adenoid Facies
Weight:
Vitals:
Pulse rate : Respiratory rate :
Blood pressure (>15 years ) : Temperature :

ENT EXAMINATION :
ORAL CAVITY :
Oral hygiene – Good / Poor
Lips
Angle Of mouth
Gingivolabial Sulcus
Gums
Gingivobuccal sulcus
Teeth- Dental formula
Buccal Mucosa
Floor of mouth
Anterior 2/3rd of Tongue
Hard palate
Retromolar trigone
OROPHARYNX:
B/L Tonsils enlarged- Grade – left and right
Anterior Pillars – Congested
Posterior pillars Not seen (Grade 2,3,4)
 Soft palate -NORMAL
Uvula in midline
Posterior Pharyngeal wall – Normal

NOSE:
External Contour
Vestibule and columella

Anterior Rhinoscopy:
Right Left
Nasal septum C/S shaped DNS/ Spur
Nasal mucosa Congested / Pale / Pink
Nasal Floor Secretions / Foreign bodies
Nasal cavity Polyps / Mass/ Adhesions
Inferior Turbinate Hypertrophy
Inferior Meatus Secretions / Pus
Middle turbinate Concha Bullosa / Double MT
Middle meatus Secretions / Polyps
Roof Polyp/ secretions

Posterior Rhinoscopy examination

➢ Posterior end of septum
➢ Posterior end of middle turbinate and inferior turbinate
➢ Eustachian tube
➢ Fossa of Rosenmuller
➢ Roof of nasopharynx Posterior pharyngeal wall
EAR
Pre auricular area
Pinna
Post auricular area
EAC
TM

NECK :
B/L jugulodigastric nodes Palpable ,Enlarged ,size , tenderness/ non
tender
Consistency (firm), Mobile, discrete.

DIAGNOSIS:
Chronic Adeno tonsillitis (f present – with Acute exacerbation).