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Document from Ayesha Batool 2

The document outlines a systematic approach for history taking in patients with ear complaints, including biodata, presenting complaints, and detailed history of present illness. It emphasizes the importance of chronological order in documenting symptoms such as earache, discharge, hearing loss, tinnitus, and vertigo, along with relevant medical, surgical, family, and personal histories. Additionally, it provides a differential diagnosis for conditions affecting the external and middle ear.

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15 views

Document from Ayesha Batool 2

The document outlines a systematic approach for history taking in patients with ear complaints, including biodata, presenting complaints, and detailed history of present illness. It emphasizes the importance of chronological order in documenting symptoms such as earache, discharge, hearing loss, tinnitus, and vertigo, along with relevant medical, surgical, family, and personal histories. Additionally, it provides a differential diagnosis for conditions affecting the external and middle ear.

Uploaded by

alimurtaza22877
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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HISTORY TAKING – EAR

(For the case of ear complains, start with intro, consent, and availability of staff,
if the patient is male, a male staff, and female, a female staff for exposure.
Redrape at the end)
• BIODATA
Name

Age
Sex
Marital Status
Residence

Mode of admission ( w exact date and time)


e.g, My patient Muhammad Dawood, age of 18 years, unmarried, resident of Sahiwal presented
to us in OPD at 10.00 AM on 15th March.

• PRESENTING COMPLAIN
In CHRONOLOGICAL ORDER (any 03 MAXIMUM)
- EARACHE
- EAR DISCHARGE
- HEARING LOSS
- TINNUTIS
- VERTIGO

• HISTORY OF PRESENT ILLNESS


My patient was in usual state of health _ years back until he developed (whatever the case is)

(Positive findings first and then all the negative findings)


- EARACHE (most common) – complete ODPARA for HOPI
- EAR DISCHARGE (kaan se raisha)
- HEARING LOSS (unilateral, bilateral) – complete ODPARA for HOPI
- TINNUTIS (kanon mein shor sunayi deta hai) – ODPARA for HOPI plus ask for
diabetes, increased age HTN, hearing loss as its associated factors (not a
psycological issue)
Tinnitus raat ko ziada feel hota hai, for this lifestyle modification is recommended, TV
chala k sojayein, clock ki tik tik pe dehaan dein.
- VERTIGO ( PC - chakkar aarhay hain, meray ird gird sab ghoom raha hai)

O onset

D duration
P progression (intermittent, continous)

A aggravating factors

R relieving factors (ear drops, medication)


A associating factors (headache, fever, sorethorat, flu, hearing loss – sunayi theek se de raha
hai ya nahi)
Also check if the complain is unilateral or bilateral, complete or partial.

EAR DISCHARGE colour, consistency, quantity, blood stained or not, PND associated w sore
throat.

• PAST MEDICAL
Patient isse pehle kabhi ksi marz ki waja se hospital aya hai.
Diabetes, HTN, Asthma, Ischemic heart disease

• PAST SURGICAL
Any surgical history

• FAMILY HISTORY
Family – HTN, Asthma, Diabetes, IHD, TB, AIDS, Hepatitis

• PERSONAL HISTORY
Previous history of any case of ENT is imp.
Trauma – kaan mein paani tou nahi gaya, chot to nahi lagi kabhi. (Only for personal history, not
family)

Smoking, Tobacco, Use of Addictive Drugs


Sleep
Appetite

• DRUG HISTORY
Previous medications, if used any.
Or any ongoing treatment

• OCCUPATIONAL HISTORY
• ALLERGIC HISTORY
• SOCIOECONOMIC STATUS
Ghar kach’ha hai ya pakka
Ghar mein afrad kitnay hain
Kamanay walay kitnay hain
Gas, pani, electricity ati hai?

Khana gas pe banatay ya lakriyan jala k

• D/Ds
External ear
- Impacted ear wax (kaan band hai)
- Otitis Externa also presents as boils of ear
- Otistis Media
- Otomycosis (fungal infection)
Dard k sath kharish hai, with whitish, yellowish, blackish discharge. Flora is aspergillus
fumigatus and candida albicans for white discharge and aspergillus niger for black discharge
- Otosclerosis
- Minnerie’s disease

MIDDLE EAR
- Suppurative Otitis Media (pus discharge- acute, if the history is less than 03
months, and chronic, if the history is of more than 03 months)
- OME Otitis Media with effusion (in children, eustachian tube dysfunction, fluid
accumulates, hearing loss)

SADIA HANEEF -137


S9 - SLMC

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