Ear case presentation in ent

1. Ear case presentation
BY DR V SANKAR NAIK

2. A female patient by name
kameswaramma of age 39 years ,who
is a resident of venkatachalem came
to ENT OPD with chief complaint of
right ear discharge since 3 months
Chief complaints :

3. HISTORY OF PRESENTING ILLNESS
Patient was apparently normal 3 month back , then she developed
right ear discharge which was insidious in onset ,gradually
progressive in nature , no foul smell , string in consistency ,
plurent type, cremish yellowish colour, not associated with blood
stained discharge. Symptoms temporarily reduced on using
medications
H/O right ear decreased hearing sensation insidious in onset
progressive in nature , moderate type.

4. No h/o tinnitus
No h/o vertigo
No h/o autophony
No h/o facial nerve palsy
No h/o fever
No h/o headache
No h/o pain
No h/o complaints related to nose and troat

5. PAST HISTORY
No h/o similar complaint in past
No h/o diabetes, hypertension , asthma ,thyroid ,TB ,
epilepsy.
No h/o dust /drug allergy
Past h/o of tubectomy 17yrs back .

6. PERSONAL HISTORY
Takes mixed diet {veg & non vegetarian}
Good appetite
Sleep adequate
Bowel and bladder regular
No h/o tobacco and gutkha chewing

7. FAMILY HISTORY
No significant family history
MENSTRUAL HISTORY
Menstrual cycle regular and cyclic
,LMP- 13/6/23

8. GENERAL EXAMINATION
Patient is conscious, coherent, cooperative .
Moderately built and moderately nourished .
No signs of pallor ,icterus , cyanosis ,clubbing , pedal edema ,
generalised lymph adenopathy .
Vitals
BP = 120/80mm/hg
PR = 80 bpm
RR = 20 cpm
Temperature = Afebrile

9. SYSTEMIC EXAMINATION
• CVS = S1 S2 normal .No murmurs
• RS = B/l air entry present , no added
sounds
• P/A = soft
• CNS = No focal neurologic deficits

10. LOCAL EXAMINATION
RIGHT LEFT
pinna normal normal
Pre auricular region normal normal
Post auricular region normal normal
Post auricular sulcus normal normal
EAR EXAMINATION
ON INSPECTION

11. ON PALPATION
RIGHT LEFT
MASTOID
TENDERNESS
ABSENT ABSENT
TRAGAL
TENDERNESS
ABSENT ABSENT
TENDERNESS OF
PINNA
ABSENT ABSENT

12. BULLES EYE LAMP EXAMINATION
PINNA
EAC
TM

13. Right ear

14. FUNCTIONAL TEST
RIGHT LEFT
RINNE’S TEST negative positive
WEBER’S TEST Lateralised to poor ear
ABC Same as examinar Same as examinar

15. NOSE EXAMINATION

16. TROAT EXAMINATION
ORAL CAVITY : dental caries present
OROPHARYNX: NORMAL

17. PROVISONAL DIAGNOSIS
Right chronic suppurative otitis media
( tubotympanic type ) with out
complications