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    Throat Hisotry

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    117shivsankarisp
    This document provides a template for examining a patient's throat. It includes sections for collecting information on the patient's chief complaints, history of present illness, past medical history, general examination, and ENT examination of the oral cavity, oropharynx, nose, ears, and neck. The examination evaluates symptoms, appearance of the throat and tonsils, and palpation of lymph nodes to diagnose conditions like chronic/acute tonsillitis or adenoid hypertrophy.

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    Throat Hisotry

    Uploaded by

    117shivsankarisp
    14 views5 pages
    This document provides a template for examining a patient's throat. It includes sections for collecting information on the patient's chief complaints, history of present illness, past medical history, general examination, and ENT examination of the oral cavity, oropharynx, nose, ears, and neck. The examination evaluates symptoms, appearance of the throat and tonsils, and palpation of lymph nodes to diagnose conditions like chronic/acute tonsillitis or adenoid hypertrophy.

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    Throat hisotry

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    This document provides a template for examining a patient's throat. It includes sections for collecting information on the patient's chief complaints, history of present illness, past medical history, general examination, and ENT examination of the oral cavity, oropharynx, nose, ears, and neck. The examination evaluates symptoms, appearance of the throat and tonsils, and palpation of lymph nodes to diagnose conditions like chronic/acute tonsillitis or adenoid hypertrophy.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    14 views5 pages

    Throat Hisotry

    Uploaded by

    117shivsankarisp
    This document provides a template for examining a patient's throat. It includes sections for collecting information on the patient's chief complaints, history of present illness, past medical history, general examination, and ENT examination of the oral cavity, oropharynx, nose, ears, and neck. The examination evaluates symptoms, appearance of the throat and tonsils, and palpation of lymph nodes to diagnose conditions like chronic/acute tonsillitis or adenoid hypertrophy.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 5

    HISTORY TAKING AND EXAMINATION OF THROAT

    Name (Identity): Age:


    Address:
    Informant:
    Reliability-
    If Informant is Mother – GOOD
    If Informant is Grandparents- FAIR
    If Informant is Neighbour – POOR

    Chief Complaints :
    1.Recurrent episodes of throat pain – Duration
    2.Recurrent episodes of Sore throat- Duration
    3.Pain during Swallowing – Duration

    History of Presenting Illness :


    1,2. throat pain and sore throat –
    Onset-sudden(acute)/Insidious (Chronic) , No: of episodes
    /month or year
    Nature- Pricking
    Radiating – (to ear)
    Aggravating- Cold food ,URI
    Relieving- Saline gargling, medications
    Whether pain or sore throat episodes are associated with
    episodes of Fever
    3.H/O difficulty in swallowing (Grade IV Tonsils)
    Gradual /Progressive
    H/O halitosis
    H/O Fever
    H/O Snoring
    H/O Mouth breathing
    H/O Recurrent URI (For Adenoid Hypertrophy)
    H/O Nasal obstruction
    H/O Voice change
    H/O Ear Block /Hard of Hearing → Serous Otitis Media (ET
    obstruction by adenoids)
    H/O Ear pain/ Ear discharge (Acute Otitis Media,ASOM ,SOM)
    adenoid is septic focus
    H/O Nausea ,Abdominal pain (Inflammation of Peyer’s patches)

    Past History:
    H/o Similar episodes in the past
    H/o congenital Heart disease /BA/TB /Epilepsy
    Rx history : any previous Surgeries

    Personal History:
    Mixed diet
    Bowel and bladder habits

    Family history :
    Similar complaints in Siblings, etc

    GENERAL EXAMINATION :
    Conscious , Oriented ( > 5 years) Alert,Awake,Active (<5 years)
    Afebrile
    Pallor/Icterus/cyanosis/clubbing/lymphadenopathy/edema
    No features of adenoid Facies
    Weight:
    Vitals:
    Pulse rate : Respiratory rate :
    Blood pressure (>15 years ) : Temperature :

    ENT EXAMINATION :
    ORAL CAVITY :
    Oral hygiene – Good / Poor
    Lips
    Angle Of mouth
    Gingivolabial Sulcus
    Gums
    Gingivobuccal sulcus
    Teeth- Dental formula
    Buccal Mucosa
    Floor of mouth
    Anterior 2/3rd of Tongue
    Hard palate
    Retromolar trigone
    OROPHARYNX:
    B/L Tonsils enlarged- Grade – left and right
    Anterior Pillars – Congested
    Posterior pillars Not seen (Grade 2,3,4)
    Soft palate -NORMAL
    Uvula in midline
    Posterior Pharyngeal wall – Normal

    NOSE:
    External Contour
    Vestibule and columella

    Anterior Rhinoscopy:
    Right Left
    Nasal septum C/S shaped DNS/ Spur
    Nasal mucosa Congested / Pale / Pink
    Nasal Floor Secretions / Foreign bodies
    Nasal cavity Polyps / Mass/ Adhesions
    Inferior Turbinate Hypertrophy
    Inferior Meatus Secretions / Pus
    Middle turbinate Concha Bullosa / Double MT
    Middle meatus Secretions / Polyps
    Roof Polyp/ secretions

    Posterior Rhinoscopy examination


    ➢ Posterior end of septum
    ➢ Posterior end of middle turbinate and inferior turbinate
    ➢ Eustachian tube
    ➢ Fossa of Rosenmuller
    ➢ Roof of nasopharynx Posterior pharyngeal wall
    EAR
    Pre auricular area
    Pinna
    Post auricular area
    EAC
    TM

    NECK :
    B/L jugulodigastric nodes Palpable ,Enlarged ,size , tenderness/ non
    tender
    Consistency (firm), Mobile, discrete.

    DIAGNOSIS:
    Chronic Adeno tonsillitis (f present – with Acute exacerbation).

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