History taking in a case of CSOM with central perforation

2. A case of CSOM with central perforation
(Tubo-tympanic disease)

3. PATIENT PARTICULARS
• Name
• Age
• Sex
• Religion
• Occupation
• Address
• Date of admission
• Today I am going to present the history of (age) year old, male/female (name).
He/she is a (religion) by religion and works at/as (occupation) in (city) and is a
permanent resident of (address).

4. CHIEF COMPLAINTS
He/she presented in the out patient department of ENT with chief complaints of:-
• In chronological order : Disease which started first.
Right ear discharge – 2 years.
Difficulty in hearing – 1 year.
Ringing sensation in ear – 6 months.
Fever – 1 week.

5. H/O PRESENT ILLNESS
• Patient was apparently alright 2 years back when he/ she started with (complaint).
• First describe the 1st chief complaint then its associated symptoms and relevant negative history.
• Then go on 2nd chief complaint and like wise.
• Then negative history of overall disease picture.
• Patient was apparently alright 2yrs back when he/ she started with discharge from right/ left ear, which was primarily serous/
mucoid in nature, but gradually became purulent with sensation of ear fullness over 10 days duration. The discharge is non-
offensive, copious in amount, mostly appears at the time of URI or on entry of water in the ear. He/ She experienced similar
episodes for about 6-7 times in last 2yrs. He/ She has a positive h/o pond-bathing for about 10-12yrs prior to the onset of his/her
symptoms.
• She had experienced earache in her 1st 2-3 episodes, but the earache gradually diminished and now at the time of presentation,
there is no earache.
• He/ She has also developed u/l (Rt/ Lt) ear deafness since last 1yr with intermittent episodes of vertigo (not much significant).
• He/ She also complains of ringing sensation/ tinnitus in both ears (Rt & Lt) since last 6 months, which is continuous & non-
pulsatile in nature.
• He/ She also has fever at the time of presentation, which is since last 1wk, which is intermittent in nature, of mild - moderate
grades, may occur at any time of the day.
• There is no h/o injury to the ear or vomiting or itching or lacrimation or facial palsy a/w his/ her symptoms.

14. H/O PAST ILLNESS
• History of Tuberculosis/ Syphilis/ Leprosy/ Epilepsy.
• History of infectious fever - Measles/ Chicken pox/ Typhoid.
• History of trauma or allergy.
• Any history of previous surgery.
• History of diabetes and hypertension.
• Diseases of CNS & Others.
FAMILY HISTORY
• Members of family.
• Similar complaints in any other member in the family.
• History of T.B./Diabetes/ Hypertension in any family member.
• Duration.
• Onset.

15. PERSONAL HISTORY
• Diet/ Sleep/ appetite
• Micturition/ bowel habits
• Habits: Smoking/ Pan chewing/ Alcohol intake
• Hygiene/Socio-economic Status
• Exposure to dusty atmosphere or chemical irritants or fumes
OTHERS
• Menstrual History.
• Socioeconomic history.
• Immunization history – in case of a child.
• Children: examiner should be told about the person from whom you have taken
history, e.g. Mother in case of a child.

16. GENERAL PHYSICAL EXAMINATION
• Mental status-- Orientation to time, place & person
• Facies
• Pallor/ Icterus/ Cyanosis/ Clubbing/ Pedal oedema/ Generalised Lymphadenopathy
• Built
• Nourishment
• Vital data:
 Pulse
 SPO2
 Respiratory rate
 Blood pressure
 Temperature

17. SYSTEMIC EXAMINATION
• CVS – S1, S2 heard, no audible murmurs.
• RS – normal vesicular breath sounds heard, no crepts, no wheezing.
• CNS - Higher mental functions, Motor functions, Sensory functions - normal.
• Cranial nerves – facial nerve, olfactory, hypoglossal, vagus, glossopharyngeal,
trigeminal, auditory nerve.
• Per Abdomen- soft, non tender, no organomegaly.

18. LOCAL EXAMINATION
• EXAMINATION OF PINNA
• EXAMINATION OF POST-AURICULAR REGION
• EXAMINATION OF EAC
 WITH SPECULUM
 WITHOUT SPECULUM
 OTOSCOPIC/ OTO-ENDOSCOPIC
 EUM
• EXAMINATION OF TYMPANIC MEMBRANE

19. EXAMINATION OF PINNA

40. EXAMINATION OF TYMPANIC MEMBRANE

41. EXAMINATION OF TYMPANIC MEMBRANE

50. EXAMINATION OF MIDDLE EAR

51. EXAMINATION OF EUSTACHIAN TUBE PATENCY

52. EXAMINATION OF EUSTACHIAN TUBE PATENCY

53. EXAMINATION OF EUSTACHIAN TUBE PATENCY

54. EXAMINATION OF EUSTACHIAN TUBE PATENCY

55. EXAMINATION OF EUSTACHIAN TUBE PATENCY

56. EXAMINATION OF EUSTACHIAN TUBE PATENCY

57. TUNING FORK TESTS

58. TUNING FORK TESTS

59. TUNING FORK TESTS

60. TUNING FORK TESTS

61. TUNING FORK TESTS

62. FISTULA TEST

63. EXAMINATION OF FACIAL NERVE

64. EXAMINATION OF FACIAL NERVE

66. PROVISIONAL DIAGNOSIS
This is a case of COM with central perforation
with moderate conductive hearing loss with no
mastoiditis and no facial nerve palsy/ any other
complications……☺☺☺