This document provides guidance on taking a thorough history from a patient in otolaryngology. It emphasizes the importance of listening to the patient, establishing rapport, and collecting relevant details on the chief complaint as well as past medical, surgical, family, social and medication histories. A complete history is essential for appropriately examining the patient and making an accurate diagnosis.

2.  Otorhinolaryngology
 Oto – Ear
 Rhino – Nose
 Laryngo – Larynx (Throat)
 Otolaryngology – Head and Neck Surgery
 Both Medical and Surgical field (10%)
 All age groups
 Patience and practice – narrow dark cavities

3.  Listen – Heart of good history taking
 Patience with open mind
 Observe/vigilant
 Relatives
 Opening greetings – Patient at ease
 Good eye contact
 Patient’s own language
 Remember – patient too assesses you

4.  Name
 Age
 Sex
 Religion
 Social status
 Occupation
 Residential address
 Chief Complaints
 History of presenting illness
 Past History; Drug History, Treatment History, Allergy
History
 Personal History
 Family History
 Immunisation History

5.  NAME psychological benefit
 Mr, Mrs , Miss, Shri , Smt
 AGE Nasopharyngeal angiofibroma
 Cancers
 SEX Thyroid – F,Larynx ca –M,cracked
voice-M
 RELIGION Ca Penis – X Jews, Muslims-
circumcision
 Social Status high, low
 Occupation Allergies, Ca,voice disorders-
singers
 Address nasopharynx ca,
rhinoscleroma,Peptic ulcers

6.  In patient’s own words
 2-3 chief complaints
 Chronological order as they occur
 according to severity
 Duration Short with pain - acute inflammatory
 Long without pain – neoplastic
 Long with slight pain – chronic inflamm
 Long with severe pain – malignant


7.  Mode of onset – sudden, gradual
 U/L or B/L. U/L – side, B/L – worse side
 Duration
 Progress – slow , rapid, increasing, declining or
CONSTANT
 Continous or intermittent/fluctuating (duration)
 Factors aggravating or relieving/preceding
events
 Treatment since when and where
 How it has impacted life style
 LOOK FOR NEGATIVE ANSWERS

8.  Nasal obstruction
 Nasal discharge
 Nasal bleed
 Post nasal drip
 Headache and facial pain
 Swelling and deformity
 Disturbance of smell
 Sneezing
 Change in voice
 Snoring

9.  U/L or B/L
 B/L – both side together or alternate
(emotional/stress)
 U/L – FB (child), DNS, ITH, AC polyp
 B/L – adenoid, allergic rhinits, polyp
 Complete/partial
 Continous/intermittent
 h/o injury, surgery, FB, allergy, bleeding
 Short duration (acute/FB), long (chronic)
 Dryness of nose and throat

10.  Watery – CSF Rhinorrhoea, common cold,
VMR, Allergic rhinitis (mucoid)
 Purulent – infections
 Blood stained – FB
 Colour
 Duration
 Foul smell
 Post nasal drip (hawking) – allergy,
infection, adenoids

11.  Children – little’s area (nose pricking)
 Elderly – HTN/malignancy
 h/o anticoagulant therapy, aspirin
 h/o bleeding disorders
 Young adult profuse bleed and anaemic –
angiofibroma
 h/o trauma
 Mild/moderate/severe
 FB
 Mainly U/L

12.  Well localised pain – nasal etiology
 Site/type/severity/periodicity
 h/o poor vision, anaemia, HTN, neuralgia, lesion
 Acute pain/chronic dull
 Furuncle
 Frontal sinusitis – morning worse lessens by
evening, frontal heaache/office
headache/bending head
 Maxillary sinusitis – face/maxilla, upper dental
 Ethmoidal sinusitis – behind eyeball, spectacle
headache, medial canthus, side of nose
 Sphenoidal sinusitis – occipital pain, vertex

13.  Anosmia – total loss – viral, neurological
 Hyposmia – partial loss – nasal obstruction
 Cacosmia – purid odour – empyema of
maxillary sinus
 Parosmia – perversion of sense of smell
 Hyperosmia – hysterical
 h/o trauma, allergy, polyp, FB
 CHANGE IN VOICE- hypernasal/ hponasal

14.  Normal protective nasal reflex to clear
secretions
 Due to irritation –
infection/allergy/inhalation
 More than 8-10 together – pathological
 Allergy to house dust, pollen, animal hair
 Relation to season/ diet/ place
 SWELLING AND DEFORMITY
 DNS/ Trauma/ Mass
 Congenital/ acquired

15.  Sound made by vibration of soft palate
during sleep while patient is breathing
through mouth
 Hypertrophic adenoids
 High arched palate
 ITH/ polyp/ DNS
 Allergic conditions
 Collapse of nasal ala
 FB SENSATION IN NOSE

16.  Treatment for the same illness in the past or
any other illness
 Diabetes, HTN, Bleeding disorders, TB,
Asthma, HIV, HBV, STD,liver or kidney disease
 Surgeries, hospital admissions, Trauma
 Deliveries and pregnancies
 Drug history- at present or past- steroids,
insulin, ocp, anti hypertensives, nasal
decongestants
 Allergy history – drugs or diet or allergen
 FOR DRUG ALLERGY – WRITE IN RED

17.  Life style – exercise, sedentary
 Food habits – regular-irregular, spicy-non
spicy, nonveg- veg, excess tea or coffee
 Work place – dusty enviroment
 Home – dampness, pets, hobbies
 Alcohol, Tobacco – quantity, quality
 Sexual life
 Bladder & Bowel habits
 Menstrual history

18.  Enquire about parents, siblings and children
 h/o similar illness in family
 Familial diseases like Peptic ulcer, cancers,
allergies, diabetes and HTN, otosclerosis
 Infectious diseases- by contact – TB , acute
infections

19.  Children – immunisation schedule
 CONCLUSION OF HISTORY
 Ask patient about his any other concerns
 Say Thank You
 Explain the examination part and need
 Proceed to examine