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ENT HISTORY Outline

The document outlines the process for taking an ENT history, including biodata, presenting complaints, history of present complaints (HOPC), past medical and surgical history, drug and allergy history, family history, personal history, transfusion history, and socioeconomic history. It emphasizes the importance of documenting significant medical conditions and symptoms related to ear, nose, and throat issues. Specific inquiries are suggested for common complaints such as tonsillitis, ear issues, and nasal obstruction.

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Nemo
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4 views

ENT HISTORY Outline

The document outlines the process for taking an ENT history, including biodata, presenting complaints, history of present complaints (HOPC), past medical and surgical history, drug and allergy history, family history, personal history, transfusion history, and socioeconomic history. It emphasizes the importance of documenting significant medical conditions and symptoms related to ear, nose, and throat issues. Specific inquiries are suggested for common complaints such as tonsillitis, ear issues, and nasal obstruction.

Uploaded by

Nemo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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ENT History Taking

(Note: If any history is not significant do not skip


heading instead write “Not Signified”)
1. Biodata

Name

Age

Sex

Marital Status

Occupation (even housewife counts)

No Known Comorbs (Comorbidities)

Comorbs refer to any other illness that patient has beside


present condition/complaint

Checked by asking about

Taking any med right now or not

Common conditions to ask about include hyperten‐


sion, sugar, TB, hepatitis

If patient say they had illness but got treatment and


now okay then in comark we write “Treated case of
[condition name]”

If condition still present write “Patient is known case


of [condition name]”

Date Of Admission And Route (Through OPD or Emergency


Room)

Written as “Admitted on [date] through [route] due to


complaints of [condition]”

2. Presenting Complaints

For Tonsillitis

Sore throat

Dysphagia

For Ear

Ear ache

Hearing loss issues

Tinnitus

Ear discharge

For Nose

Nasal obstruction

Nasal discharge

Headache/Facial pain

Voice changes

Sneezing

Snoring

3. HOPC

According to my patient ( or patient’s attendant if


unconscious) they were in usual state of health/wellbeing
[ days ago] then they developed [first presenting complain]
then they developed [2nd complain] and so on until com‐
plaints done

Generally inquire about

Onset of symptoms

Duration of symptoms

Progression + severity of complaints

Common Complaints

In Ear Discharge Ask

Pain only or pus coming out

About discharge properties

Color

Odor

Blood

Evaluate family history if pain present

For Hearing Loss Issues

Evaluate family history on pain

Pure Tone Audiometry (PTA) done or not

Example of condition

Otosclerosis

Usual nose complaints is due to deviated nasal septum


(DNS)

Patient may present with complaint of breathing from


one nostril

Septum is convex towards side of deviation and this


convexity blocks air flow

Shortness of breath

Treatment of DNS

Done according to primary cause which may be ear


discharge

Septoplasty

4. Past History

Past Medical

Taking meds now or took before?

Past Surgical

5. Drug History

6. Allergy History

7. Family History

8. Personal History

Sleep

Micturition

Bowel

Appetite

Substance use history

Smoking

Drugs (Nasha)

PICA

9. Transfusion History

10. Socioeconomic History

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