QUIRINO MEMORIAL MEDICAL CENTER

DEPARTMENT OF

ORL-HNS

PRE- OPERATIVE CASE REPORT

CHERLAINE F. VENTENILLA, M.D.

FIRST YEAR RESIDENT
HISTORY
 GENERAL DATA

 J.P.
25 YEARS OLD
 FEMALE
 SINGLE
 7-DAY ADVENTIST
 WEST KAMIAS, QUEZON CITY
 CHIEF COMPLAINT

 EAR PAIN, LEFT

HISTORY OF PRESENT ILLNESS

 EAR PAIN, LEFT

PAIN SCALE 5/10
6 MONTHS *CHARACTERIZED AS-OLDCARTS!
PRIOR TO
CONSULT:  WITH ASSOCIATED SYMPTOMS OF:
EAR FULLNESS
TINNITUS
HISTORY OF PRESENT ILLNESS

 NO SYMPTOMS OF:
COUGH AND COLDS
6 MONTHS EAR DISCHARGE
PRIOR TO FEVER
CONSULT:  NO CONSULT DONE
 NO MEDICATIONS TAKEN
HISTORY OF PRESENT ILLNESS

 STILL WITH SYMPTOMS OF:

EAR PAIN, LEFT – NOTED INCREASE
IN SEVERITY (PS NOW 8/10)
5 MONTHS EAR FULLNESS
PRIOR TO TINNITUS
CONSULT:
 CONSULT DONE
DELOS SANTOS MEDICAL CENTER
ENT SPECIALIST
HISTORY OF PRESENT ILLNESS

 AURAL TOILET DONE

5 MONTHS  PRESCRIBED WITH CO-AMOXICLAV

PRIOR TO AND CELECOXIB WHICH PROVIDED
RELIEF
CONSULT:

 FOLLOW-UP DONE A WEEK AFTER

HISTORY OF PRESENT ILLNESS

 UPON FOLLOW UP:

AURAL TOILET WITH BIOPSY DONE

5 MONTHS  RESULT: SPECIMEN CONSISTENT WITH

CHOLESTEATOMA
PRIOR TO
CONSULT:
 SURGERY WAS ADVISED

 PATIENT WAS LOST TO FOLLOW-UP

HISTORY OF PRESENT ILLNESS

 FIRST CONSULT IN OUR INSTITUTION

 AURAL TOILET DONE

4 MONTHS
 GIVEN UNRECALLED OTIC DROPS
PRIOR TO
CONSULT:  CT SCAN AND HEARING TEST REQUESTED

 ADVISED TO FOLLOW UP ONCE WITH

RESULTS
HISTORY OF PRESENT ILLNESS

 UPON FOLLOW-UP:

ADVISED FOR SCHEDULING OF

4 MONTHS
OPERATION
PRIOR TO
CONSULT:
 REVIEW OF SYSTEMS

SYSTEMS FINDINGS

CONSTITUTIONAL NO HEADACHE OR DIZZINESS, CHILLS

SKIN NO RASH OR PRURITUS
CARDIOVASCULAR NO CHEST PAIN OR PALPITATIONS,
NO EDEMA
RESPIRATORY NO DIFFICULTY OF BREATHING
GASTROINTESTINAL NO ABDOMINAL PAIN, ANOREXIA,
NAUSEA, VOMITING, DIARRHEA OR
CONSTIPATION
ENDOCRINOLOGIC NO SWEATING, COLD OR HEAT
INTOLERANCE, POLYURIA OR
POLYDIPSIA
 PAST MEDICAL HISTORY
 NO HYPERTENSION, DIABETES, HEART AND KIDNEY
DISEASE, ASTHMA, THYROID DISEASE, TUBERCULOSIS OR
CANCER

 NO PREVIOUS SURGICAL OPERATIONS OR

HOSPITALIZATIONS

 NO HISTORY OF BLOOD TRANSFUSION

 NO ALLERGIES TO MEDICATIONS
(+) ALLERGY TO EGG/ CHICKEN
 FAMILY HISTORY

 (+) HISTORY OF HYPERTENSION- FATHER

 NO FAMILY HISTORY OF DIABETES, KIDNEY DISEASE,

ASTHMA, THYROID DISEASE, TUBERCULOSIS OR
CANCER
PERSONAL & SOCIAL HISTORY

 OCCUPATION: ADMINISTRATIVE OFFICER

 (+) MODERATE ALCOHOL BEVERAGE DRINKER

2- 3 BOTTLES, ONCE A WEEK OR ONCE IN TWO WEEKS

 OCCASIONAL SMOKER
1 STICK/DAY FOR 7 YEARS= .35 PACK YEARS
PHYSICAL EXAM
 PHYSICAL EXAM

ALERT, CONSCIOUS AND COHERENT, AMBULATORY

VITAL SIGNS:
– BP: 140/90 MMHG
– HR: 82 BPM
– RR: 18 CPM
– TEMP: 36.8 C
 PHYSICAL EXAM

SYSTEM FINDINGS

EYES PINK PALPEBRAL CONJUNCTIVAE,

ANICTERIC SCLERAE
PUPILS EQUALLY ROUND AND
REACTIVE TO LIGHT
CHEST SYMMETRICAL CHEST EXPANSION,
NO RETRACTIONS,
NO CHEST TENDERNESS, EQUAL
VOCAL AND TACTILE FREMITUS,
CLEAR BREATH SOUNDS
HEART ADYNAMIC PRECORDIUM,
PMI AT 5TH ICS MCL,
NO MURMURS
 PHYSICAL EXAM

SYSTEM FINDINGS

ABDOMEN FLABBY,
NORMOACTIVE BOWEL SOUNDS,
SOFT, NON-TENDER,
NO ORGANOMEGALY
EXTREMITIES FULL AND EQUAL PERIPHERAL
PULSES, NO CYANOSIS, NO EDEMA,
NO NAIL CLUBBING
 OTOSCOPY

 INTACT TYMPANIC MEMBRANE ON BOTH EARS

 PATENT AND NON- HYPEREMIC BILATERAL EAR CANAL
 NO TRAGAL TENDERNESS
 NO DISCHARGES, NO BLEEDING
 ANTERIOR RHINOSCOPY

 NASAL SEPTUM IN MIDLINE

 (+) CONGESTION ON BILATERAL TURBINATES
 NO MUCUS DISCHARGES
 NO EPISTAXIS
ORAL CAVITY EXAMINATION

 LIPS ARE MOIST AND SMOOTH

 NO TRISMUS

 TONGUE IS IN MIDLINE

 UVULA IS IN MIDLINE

 NON HYPEREMIC POSTERIOR

PHARYNGEAL WALL
ORAL CAVITY EXAMINATION

 (+) DENTAL BRACES

 NO DENTAL CARRIES
 PINK, SMOOTH BUCCAL WALLS
 POSTERIOR RHINOSCOPY

 ***POSTERIOR RHINOSCOPY:
NO POST NASAL DRIP
 INDIRECT LARYNGOSCOPY

 INDIRECT LARYNGOSCOPY
NON-HYPEREMIC LARYNGEAL MUCOSA
MOBILE TRUE VOCAL CHORDS, BILATERAL
ADEQUATE AIRWAY
HEAD AND NECK EXAMINATION

 NO GROSS DEFORMITIES
 NO FACIAL ASYMMETRY
 NO CERVICAL LYMPHADENOPATHIES
 NO PALPABLE MASSES
 LABORATORY &
DIAGNOSTIC IMAGING
PERTINENT DATA
DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
DISCUSSION