medical description

1. A CASE OF ANTROCHOANAL POLYP

2. PATIENT DETAILS:

3. CHIEF COMPLAINTS:
The Patient came to the OPD with chief complaints of
 Difficulty in breathing,especially during night due to
nasal obstruction on left nostril for past 4 months.

4. PRESENTING ILLNESS:
The patient was apparently normal before 4 months,then
she developed
 Unilateral nasal obstruction on left nostril for past 4
months which is
 Insidious in onset
 Slowly progressive
 Aggrevated by exposure to cold
 Relieved by taking medications
 Associated with breathing difficulties mainly increased
during night
 No seasonal variation present

5.  H/O Unilateral nasal discharge for the past 2 months
which is
 Insidious in onset
 Mucoid
 Not foul smelling
 Not blood stained
 Aggrevated by taking ice water
 Relieved by taking medication
 No crust formation seen

6.  H/o postnasal drip for past 2 months
 H/o change in voice for past 2 months
 No h/o headache
 No h/o sneezing
 No h/o cough
 No h/o epistaxis
 No h/o smell disturbance
 No h/o trauma
 No h/o facial pain
 No h/o snoring
 No h/o ear pain
 No h/o ear discharge
 No h/o tinnitus
 No h/o hearing loss
 No h/o dysphagia
 No h/o throat pain or irritation

7. PAST HISTORY:
• NO h/o similar illness in the past
• No h/o any chronic illness in the past

8. TREATMENT HISTORY:
• No h/o previous medical and surgical treatment.

9. PERSONAL HISTORY:
• Mixed diet consumer
• Normal bowel and bladder movements
• Normal sleep and appetite pattern

10. FAMILY HISTORY:
• No h/o allergy
• No relevant family history present

11. MENSTRUAL HISTORY:
• Menarche at age of 14
• Regular cycle(3/28 days)

12. GENERAL EXAMINATION:
• Patient is conscious
• Comfortable
• Oriented to time,place and person
• Moderately built and nourished
• No pallor
• Not icterus
• No cyanosis
• No clubbing
• No lymph node and thyroid enlargement
• No pedal edema

13. VITALS:
• PULSE:72 beats/min
• BLOOD PRESSURE:124/80 mm hg
• RESPIRATORY RATE:16 /min
• TEMPERATURE:98.4F
• HEIGHT:153 cms
• WEIGHT:58 kgs
• BMI:24.8

14. SYSTEMIC EXAMINATION:
• Cardiovascular system:
• SI S2 heard.
• No murmurs heard
• Respiratory system:
• Normal vesicular breath sounds heard
• No added sounds heard
• Per abdomen examination:
• Soft
• No organomegaly present
• Central nervous system:
• No focal neurological deficit

15. LOCAL EXAMINATION:
1)EXAMINATION OF EXTERNAL NOSE:
INSPECTION OF NOSE:
• Skin normal
• Nose seems to be broaden(widening of nasal bridge)
• No scar,sinus,skin discoloration,swelling,fistula,vesicles,signs
of inflammation present
• Contour-normal
• Root-normal
• Columella-normal
• Ala of nose-normal
• Tip of nose-normal
• Osteocartilagenous framework-normal

16. PALPATION OF NOSE:
• No raised temperature
• No tenderness
• No crepitations present
2)EXAMINATION OF VESTIBULE:
• No fissures
• No furuncle present
• No crusting seen
• No tumors present

17. 3)ANTERIOR RHINOSCOPY:
• Nasal septum-deviated to right side
• Nasal cavity-left nasal cavity apperars to be blocked
• Color of mucosa-pinikish red
• Mucoid discharge
• No crust formation
• Floor and lateral wall of nose-normal
• No reliable information about turbinates.

18. 4)POSTERIOR RHINOSCOPY:
Shows
• Unilateral edematous mucous membrane on left nostril
which is
• Gray white in color,
• pink congested mucosa covered with mucoid nasal
discharge
• Smooth,grows posteriorly ,globular mass filling the
choana
• No pus /bleeding present

19. 5)FUNCTIONAL EXAMINATION OF NOSE:
AIRWAY PATENCY TEST:
 COTTLE’S TEST-Negative
 COLD SPATULA TEST-Reduced fogging on left side
 COTTON WOOL TEST-Movement of cotton is slow on left
nostril
 PROBE TEST-Soft and moved up and down with the probe
and can be moved all around the polyp,does not bleeds on
touch and no pain present

20. 6)EXAMINATION OF PARANASAL SINUS:
MAXILLARY SINUS:
• Soft tissue of cheek,lips,lower eyelid,molar region has
mild swelling
• Orbit and its content- normal
• Vision -normal
• Vestibule of mouth- normal
• Tenderness- present
FRONTAL,SPHENOID,ETHMOIDAL SINUS:
Normal

21. • 7)EXAMINATION OF FACE-Normal
• 8)EXAMINATION OF THROAT-Normal
• 9)EXAMINATION OF EAR-Normal
• 10)EXAMINATION OF NECK:
Normal
No significant lymphadenopathy

22. SUMMARY:

23. • ANTERIOR RHINOSCOPY-reveals blockage of left
nasal cavity
• POSTERIOR RHINOSCOPY-Shows
Smooth globular gray white nasal mass covered
with nasal discharge seen
grows posteriorly,filling the choana
• It is soft and can be moved up and down with the
probe
• Reduced fogging on left side in cold spatula test
• Movement of cotton is slow on left nostril in cotton
wool test

24. INVESTIGATIONS:
• Nasal smear and swab for eosinophil count
• Complete blood count
• Diagnostic nasasl endoscopy
• X ray paranasal sinus(water’s view)
• X ray of the neck lateral view(CRESCENT OR DODD
SIGN SEEN)
• NCCT nose and paranasal sinuses

25. FINAL DIAGNOSIS:

26. TREATMENT PLAN
FUNCTIONAL ENDOSCOPIC SINUS SURGERY(FESS)
or
INTRANASAL POLYPECTOMY

27. THANK YOU…