This document provides guidance on taking a thorough history from an ENT patient. It outlines the key components of the history to cover, including: patient identifying information like name, age, sex; chief complaints; history of present illness; past medical, surgical, drug and allergy histories; personal and family histories; and immunization history. It describes the importance of listening to the patient, using their language, making them comfortable and remembering they are assessing you too. Sections provide more detail on questions for specific anatomical areas like the oral cavity, oropharynx and larynx. The goal is to fully understand the patient and their condition.

1. Dr Manpreet Singh Nanda
Associate Professor ENT
MMMC&H Solan

2. E.N.T
 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. Essentials
 Listen – Heart of good history taking
 Patience
 Observe
 Relative
 Opening greetings – Patient at ease
 Good eye contact
 Patient’s own language
 Remember – patient too assesses you

4. General approach
 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. To know the patient
 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. Chief Complaints
 In patient’s own words
 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
 Throat - Oral cavity, Oropharynx, Laryngopharynx and
Larynx, Neck

7. Chief Complaints in Oral Cavity
 Ulcers
 Dry mouth (Xerostomia)- mouth breathing
 Bad smell (Halitosis) –poor hygiene,ulcers,post nasal drip
 Pain
 Loss of taste (Dysgeusia)
 Excess salivation - poor hygiene, ulcers
 Tongue tie (Ankyloglossia)
 Difficulty in opening mouth (Trismus) – SMF
 Swellings
 Cleft palate
 Circumvellate papillae of tongue
 Bleeding gums - scurvy

8. Oropharynx
 Sore throat
 F.B Sensation – allergy, post nasal drip, functional, malignancy
 Difficulty in swallowing (Dysphagia)
 Pain during swallowing (Odynophagia)
 Regurgitation
 Snoring
 Foreign body

9. Larynx
 Change in voice – hoarse, cracked voice in males(puberphonia),
vocal fatigue- elders, functional
 Repeated clearing of throat- GERD, Chronic laryngitis
 Difficulty in breathing - infections, tumours
 Cough and expectoration
 Neck swellings

10. History of presenting illness
 Mode of onset – sudden, gradual
 Side
 Any cause of onset
 Duration
 Progress – slow , rapid, intermittent, continous, increasing,
declining
 Factors aggravating or relieving
 Treatment for the same, since when and where
 How it has impacted life style
 LOOK FOR NEGATIVE ANSWERS

11. Past history
 All diseases before this disease in chronological order
 Diabetes, HTN, Bleeding disorders, TB, Asthma, HIV,
HBV, STD
 Surgeries, hospital admissions, Trauma
 Deliveries and pregnancies
 Drug history- at present or past- steroids, insulin, ocp,
anti hypertensives
 Allergy history – drugs or diet or allergen
 FOR DRUG ALLERGY – WRITE IN RED

12. Personal history
 Life style – exercise, sedentary
 Food habits – regular-irregular, spicy-non spicy,
nonveg- veg, excess tea or coffee
 Smoking – frequency , quality
 IV abuse
 Alcohol – quantity, quality
 Sexual life
 Bladder & Bowel habits
 Menstrual history

13. Family history
 Enquire about parents, siblings and children
 Familial diseases like Peptic ulcer, cancers, allergies,
diabetes and HTN, otosclerosis
 Infectious diseases- by contact – TB , acute infections

14. Immunisation history
 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