case presentation proforma in otorhinolaryngology for MBBS students.

1. Case Presentation in Ear.
Dr. Rajashri Mane,
Prof & HOD,
D. Y. Patil Medical College,
Kolhapur.

2. CASE HISTORY
• Name:
• Age
• Sex:
• Socioeconomic status:
• Occupation

3. EAR
• Otorrheoa
• Deafness
• Otalgia

4. OTORRHOEA
• Unilateral/bilateral
• Profuse/scanty
• Mucoid/mucopurulent/purulent
• Foul smelling
• Blood stained
• Whether responds to medical line of treatment.
• Associated with URTI.

5. DEAFNESS
• Unilateral/bilateral
• Sudden onset/gradual
• Affecting day to day life?
• Static/progressive

6. History of complication
• vertigo/Tinnitus
• Post aural swelling/ pain
• Swelling in neck
• Facial weakness
• Diplopia, retro orbital pain
• Fever, Headache, projectile Vomitting,
unconsciousness
• Hemianopia, nominal aphasia
• Imbalance

7. History of etiology
History of
• Recurrent H/O URTI
• Odynophagia, halitosis
• Snoring, sleep disturbance, mouth breathing
• Nasal obstruction, Nasal discharge, headache
• Trauma
• Previous surgery

8. NOSE
• Associated nasal complaints-nasal discharge/
nasal obstruction/headache/post nasal discharge
• Associated throat complaints-sore throat/ pain in
throat/ difficulty in swallowing/ change in voice
• Treatment history-Medical-Tablets/
injections/local ear drops/chemical
cauterisation/surgical.

9. • Past history
History suggestive of TB/ HTN/HIV/ DM/Any other illness.
• Family history
History suggestive of TB/ HTN/HIV/ DM/Any other illness.
• Personal history
-Nutrition: adequate/ inadequate
-Diet: Veg/Nonveg/Mixed
- Sleep: Normal/Reduced
-Habits: Smoking/ tobacco chewing/ alcohol
Days/ months/years
• History of exposure to noise
• History of exposure to S.T.D’s

10. • General physical examination:
- Built: good/ moderate/poor
-Adenoid facies
-Pallor/cyanosis/jaundice/clubbing/
Lymphadenopathy/edema
- Pulse rate- /minute
-B.P. mm Hg
• Systemic examination-
-CVS
-RS
- CNS
- P/A

11. EAR EXAMINATION
RIGHT EAR LEFT EAR
• Pinna
• Pre auricular region
• Post auricular region
• Ext. Auditory canal
a)narrow/wide
b)discharge/wax/fungus
c)granulation/polyp

12. • Tympanic membrane
Right Left

13. Perforation
Number-single-multiple
Central/marginal
Small/medium/large/
Subtotal/total kidney shaped
Middle ear mucosa
Pale/pink/moist/
Inflamed/+polyp
Site of perforation
AS/AI/PS/PI/central/multiple
Margins
Ossicles- intact/necrosis/-LP incus/
IS jt/ Handle of malleus

14. TFT-
RIGHT EAR LEFT EAR
• RINNE
256Hz
512 Hz
1024HZ
• WEBER
• ABC

15. Other tests
• Fistula test
• Nystagmus
• Facial nerve
• Cerebellar signs
• Mastoid tenderness

16. PROVISIONAL DIAGNOSIS
• Right/left/bilateral,
• CHRONIC SUPPURATIVE OTITIS MEDIA
• Tubotympanic / atticoantral
• Active/ inactive/ quiscent stage
• Mild/ mod/ severe , conductive/ SN/ mixed deafness
• Without complications
• no/DNS/ITH/adenotonsillitis pathology in
nose/throat.

17. INVESTIGATIONS
• Ear microscopy
• Pus for smear, culture antibiotic sensitivity
• Pure tone audiometry
• X ray mastoid(Schullers view)
• Otoendoscopy

18. TREATMENT
EAR-central perforation
Active-conservative treatment-
• Aural toilet
• Antibiotics
• Nasal decongestant
• anti- inflammatory analgesics
• local ear drops
After acute infection subsides-surgery- Tympanoplasty
Dry ear-surgery-Tympanoplasty under local anaesthesia
with sedation.

19. Thank you.