Case Presentation proforma in Nose for MBBS students

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

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

3. NOSE
Chief complaint
• Nasal obstruction
• Nasal discharge

4. Nasal obstruction
• Unilateral/bilateral
• Intermittent/continuous
• Progressive/static
• Aggravating/relieving factors
• Diurnal variation
• Positional variation

5. Unilateral continuous
• DNS
• AC polyp
• F B
• Neoplasm
• Rhinolith
• rhinosporidiosis
Unilateral intermittent
•Turbinate hypertrophy
•sinusitis

6. Bilateral continuous
• DNS & Inferior turbinate hypertrophy
• Ethmoid polyps
• Adenoids
• Atrophic Rhinitis
• Rhinoscleroma
• Neoplasm

7. Bilateral intermittent
• Allergic Rhinitis
• sinusitis

8. Nasal discharge
• Watery/mucoid/mucopurulent/blood stained
• Foul smelling/non foul smelling
• Unilateral/bilateral
• Aggravating/relieving factors-at time of URTI/exposure to cold
environment

9. • Watery -- Allergic Rhinitis
vasomotor Rhinitis
CSF Rhinorroea
• Purulent – sinusitis
• Faul smelling – Atrophic Rhinitis
FB in children
Malignancy in adults

10. History of complication
History of
• Epistaxis
• Sneezing(Allergic rhinitis)
• Watery discharge(CSF Rhinorrhoea)
• crusting/dryness/foul smell(Atrophic rhinitis)
• headache/post nasal discharge(Sinusitis)

11. • Throat pain/ odynophagia/ halitosis/ dry cough
• Ear discharge/ pain / deafness

12. History of etiology
History of
• Trauma
• Surgery

13. • Associated ear complaints-ear discharge/ear
blockage/diminished hearing
• Associated throat complaints-sore throat/pain in
throat/difficulty in swallowing/change in voice
• Treatment history-
Medical-tablets/injections/local nose drops
Surgical

14. • 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

15. • 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

16. NOSE EXAMINATION
• External appearance
Inspection
Palpation
Root, dorsum, tip, ala, collumella
• Cold spatula test
• Vestibule

17. Anterior rhinoscopy(ARS):
• Nasal mucosa- pale/congested/bluish
• Septum- deviated/straight/perforated
• Lateral wall- inferior and middle turbinates & meati
• Floor-Any growth/polyp/presence of mucopus

18. Posterior rhinoscopy(PRS):
• Choana
• ET orifice
• Fossa of Rosenmuller
• Roof of nasopharynx
• Soft palate

19. Paranasal sinus(PNS):
• Inspection- oedema/cellulitis
• Palpation- tenderness of frontal/ethmoid(R/L)/maxillary(R/L)

20. PROVISIONAL DIAGNOSIS
• Deviated nasal septum to right/left with
• caudal dislocation to right/left with
• right/left/bilateral spur in floor with
• right/left sided ITH with
• no/CSOM/Sinusitis/adenotonsillitis pathology in ear/throat.

21. INVESTIGATIONS
• Diagnostic Nasal Endoscopy
• X ray PNS waters view

22. NOSE-deviated nasal septum
Active infection-conservative treatment-
• antibiotics
• Antihistaminic
• Nasal decongestant ( local & systemic)
• Anti inflammatory
• Nose drops
After acute infection subsides-surgery-Septoplasty
• Inactive- surgery- Septoplasty under local anesthesia
with sedation.

23. Thank You.