DEPARTMENT OF ENT Gandhi Medical College, Bhopal

Registration/Case no. DateRSO in charge: Ward/OPD:

Name of patient:Age/sex:Address: Religion: Occupation:

HISTORY:Presenting complaints:

H/O presenting complaints:

Past illness:

Personal history:

Obs/Mens history:

Social history:

Family history:

Treatment history:

EXAMINATION:General examination:

Systemic examination:

ENT examination: EAR Right LeftPreauricular region

Pinna

Postauricular region(including mastoid)

EAC

TM

Right LeftTuning fork tests *Rinnes test

*Webers test

*ABCEustachian tube(Valsalva maneavur)

Facial nerve

SpontaneousNystagmus

Rombergs test

Fistula test

Caloric test

Gait assessment

NOSENasal profile:

Nasal passages:

DIAGRAM: Right Left

Patency:

Olfaction:

Palpation:

Anterior rhinoscopySeptum:

Floor:

Roof:

Lateral wall(inf/middle turbinate):

Nasopharynx:

Paranasal sinuses:Sinus Maxillary Frontal Ethmoid

Inspection

Palpation

Transillumination

THROAT:Oral cavity:

Voice:

Lips:

Buccal mucosa:

Gums and teeth:

Tongue:

Floor of mouth:

Hard palate:

Retromolar trigone:

Oropharynx:

Anterior pillar:

Posterior pillar:

Tonsil:

Base of tongue:

Posterior pharyngeal wall:

Indirect laryngoscopy:

NECKLymph nodes of head and neck:

DIFFERENTIAL DD:

INVESTIGATIONS:

RX

Case summary:

Date: Signature:S.No. CASE STUDY Date Remark

ENT RECORD BOOK GANDHI MEDICAL COLLEGE,BHOPAL

NAME: ROLL NO.: SESSION/YEAR:

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