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Practical View of ENT

‫ ـــ
اــــ‬.‫د‬

2014
Practical View of ENT 2

Case presentation
Format of the case presentation in order:-
1.Report the history, in standard format.

2. Describe ph. examination, in standard format.

3. Report the basic laboratory data.


4. Summarize the case (in chronological order, Ho, Rx).

5. Assessment (including DDs & professional Dx.).

6. Plan: your recommendations for invest. &managem.

7. Final Dx. &management.

Report the history, in standard format :-


• Personal History
• Chief complaint
• History of the present illness
• Review of systems (Related)
• Past History
• Family History
• Socioeconomic History
Practical View of ENT 3

Golden rules for History Taking


1. Pt.should be encouraged.

2. Use simple language

3. Don’t interrupt pt. narration.

4. Avoid leading questions.

5. Carefully take past medical hist.

6. Hist. should be in chronological order.

7. Check accuracy without accusation .

8. Check contraindications by question.

9. Failing memory of the pt. is considered.

10. There are key questions for each disease.

Personal History
• Name
• Age
• Sex
• Residence
• Occupation
• Habits (of medical importance)
• Marital status
• Date of Admission
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Chief complaint
• In pt. wards
• The most important comp.
• with it’s duration
• One or tow comp.
History of Present illness :-
• Use medical terms
• In chronological order that leads to Dx.
• Mention the related negative symptoms
• Analysis of CC: (( SOCIAL )) :-
S=Site or Side
O=Onset , Odor , Other complain .
C = Course , (duration ) , Character
I = Intensity , Infection , Injury , Remember
Frequency .
A=Associated symptoms ( see symptoms of of
ENT in this notes ) , Aggravating factors ,
Relieving
L = Last attack , Last for ,Local symptoms ,
= =Loss of function , Lifestyle effect , Late and
early complications ,
= Last ICE ( Idea of the patient about his --
disease , Concern , Expectation ).
Practical View of ENT 5

Review of Systems –Related :-


• Respiratory
• Neurology (including Cr. N. & Eye)
• Cardio.V.S
• Gastro.I.T
• Musculo.SK
Past History :-
(( ‫ت و'"ج‬#( )
*‫
ا  دم وأ‬,-‫ و‬$‫"ا‬# $ ! ‫)وا  دث وأ ا ا 
ا 
ت وا‬

• head trauma
• Hospitalization
• Medical conditions
• Radiation &noise Exposure
• Surgical hist
• Blood transfusions
• Drugs, allergy & ototoxicity
• Same condition
Family History :-
• Same condition
• Other diseases; atopy, deafness.
• Consanguinity
• Partners, siblings, & offspring
Socioeconomic History :-
• Income
• Housing
• Sanitation & Hygiene
Practical View of ENT 6

Symptomatology
i. Symptoms of Ear
( DVT IS PAINFULL )

D= Deafness , Discharge , dizziness , deformity .


V=Vertigo , Vomiting & other neurological symptoms
T=Tinnitus.
I=Injury
S=Swelling , swimming
P=Pain , Pack ( blockage )
A=Autophony
I= Itching
N=Neoplasm
F=Fullness , Facial palsy
L=Lacrimation
L=Loss of equilibrium
Notes :- other neurological symptoms :-

Headache , neck stiffness , fever , cervicofacial pain , diplopia , focal


signs &altered mental status.
Practical View of ENT 7

ii. Symptoms of Nose


( NOSE CDEFGH)
 N= Nasal discharge
 O=Obstruction
 S4=
 S1 =Sneezing
 S2= Smell change
 S3= swelling
 S4=Snoring, Sound ( whistling )
 E=Epistaxis
 C = Cough , Crustation
 D4 =
1. D1=Dryness
2. D2 = Dental pain & burning
3. D2=drip post-nasally
4. D3=Deformity& trauma .
 E= Ear pain , Eye watery , Eye discoloration
 F= Fever , F.B sensation
 G=Generalized fatigue
 H= Halitosis , Headache.
Practical View of ENT 8

iii. Symptoms of Oral cavity & pharynx


(THRUSH LAB)
 T=Taste change, Trauma
 T= Trismus , Temperature increased
 H=Halitosis
 R=Respiratory difficulty
 U = Ulcer
 S :-
 S1=Swallowing difficulty , weigh loss
 S2=Sensation of pain or burning ,F.B .
 S3 = Swelling
 S4= Snoring
 H=Hearing loss & otalgia
 L=Loose or ill-fitting denture , loss of vision , diplopia,epiphora

 A=Abnormal speech , Anorexia


 B=Bleeding
Practical View of ENT 9

iv. Symptoms of Salivary gland


(S6)
 S1=Swelling
 S2 = Swelling asso. with pain in eating
 S3 = Swelling in neck
 S4 = Sinus with fistula
 S4 = Symptoms & Signs of malignancy
 S6 = Saliva amount
v. Symptoms of Obstrutive Sleep Apnea :-
 In child :-
( APO SMAH GASP HER )
Daytime symptoms Nighttime symptoms
ABO SMAH GASP HER
A = Attention deficit G=Gasping
P=Poor school performance A=Apnea
O = Obstruction of the nose S= Snoring, sweating
S= Somnolence P = Paradoxical breathing
M= Mouth breathing H=Hyperextension neck
A=Aggressive behavior E=enuresis
H=Hyperactivity behavior R=Restless of sleep
A = Aggressive behavior,
Alter of speech

 In Adult :-
(DSMA ) ‫د‬
 D=Daytime sleep , Diturb sleep
 S= Snoring , Sleep latency decrease
 M =Morning headache , Memory poor
 A=Apnea
Practical View of ENT 10

vi. Symptoms of Larynx


(VOCAL FOLDS )

V=Voice disorders
O=Odynophagia , pain
C=Cough
A=Abnormal breathing
L=Lump in the neck
F=Foreign body sensation
O=Other complain
L=Lump in the throat
D=Dysphagia
S=Stridor
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2.Describe Ph.exam.In standard format


• General examination
• Systemic examination (as indicated)
• Local Head & Neck examination

Physical Examination divided to


A. Start of examination
B. Proper Examination
C. Finish of Examination

A. Start of examination :-
(( I Want PERmission,CHAPERON, ASK And
Do Gently ))
 I = Introduce your self
 W = Wash your hand by gel
 P = Permission ,

= Position :-

1. Sit facing the pt & your knees together & to the Rt. Of pt. knees

2. Fit head light,L.sourse on the Lt.shoulder of the pt.(30-50cm of


mirror which is on your Rt. Eye.

3. Use the hand opposite to the examined ear.

 E= Explain , Exposure .
 Chaperon = relative
 Ask = Ask for any pain or tenderness ( to start with normal location
or site )
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 And = Any instrument to be used :-


 Fiber optic endoscope :- the scope handle in dominant hand ,
the lens in other hand .
 Hold nasal speculum in the Lt. hand.
 It is better to be able to draw what you see.
 Pen like hold otoscope ,lymph node , pharyngeal mirror
&probe.
 Do :- Draw what you see
Gently = Gentle exam should always be done & General overview at
beginning .
B. Proper Examination
 General examination :
Mental status (Con., Or., Coop.)
Appearance (look, comfort, wellness, distress,
syndromes, frank deformities & surroundings)
JACOB (Jaundice, Anemia, Cyanosis, Oedema, Built)
Vital Signs
 Systemic examination (as indicated)
Respiratory; norm. ves.br.&abnor. sounds
CVS; S1+S2 & murmur
Abdomen; consistency,organomegaly
CNS; focal defect(motor, sensat.,tone)

AS indicated
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 Local H & N examination :-


10 components in order ( up down, out in (ENT H&N ))
Ear --------------------------------------E
Nose -----------------------------------N
Oral cavity
Oropharynx
Nasopharynx T
Hypopharynx
Larynx
Face, Eye & Scalp
Neck H&N
Cranial nerves &

as indicated

 By & about
By
• Inspection
• Palpation
• Percussion
• Auscultation
ABOUT
(AS DRUG)
• Asymmetry
• Swelling
• Discoloration
• Restriction
• Ulcer
• Growth
Practical View of ENT 15

 Local ENT, H & N examination :-


 EAR Examination

Pinna

3P Preauricular

Postauricular

Meatal externa

3M Membrane

Middle ear

Fistula test

3F Field & fork

Facial N

Nose & Throat

3N Neck

Necked eye

Audio test

3 Extra test(ABC) Balance test

Cranial Ns
Practical View of ENT 16

 Pinna , Preauricular , Postauricular examination

( PSCC , H , A )

i. 1st :- The Pinna exam :-


• P=Position
• S=Swelling , Sinus, Secretion , Scar
• CC= Color, Congenital deformity , Compare .
• H=Hair
• A=Auscultation if needed.
ii. 2nd :-Preauricular exam
• P=Press tragus
• S=Swelling , Sinus, Secretion , Scar
• CC= Color, Congenital deformity , Compare .
• H=Hair
• A=Auscultation if needed.
iii. 3rd :- postauricular exam
• P=Press 3 fingers test
• S=Swelling , Sinus, Secretion , Scar
• CC= Color, Congenital deformity , Compare , Crease
• H=Hair
• A=Auscultation if needed.
Practical View of ENT 17

 Meatus Exam
(MEATUS)

• M=Mass
• E= Ext.F.B
• A = Atresia or wide
• T=Tissue ( granulation)
• U = Ulceration
• S= Secretion , Swelling ,Sinus
 Middle ear exam
(Middle)

• M=Mucosa
• I=Intact or erosive ossicles &scutum
• D = Discharge
 Tympanic membrane examination
( LPSC – Mobile ./ )

• L = Landmark
• P = Position
• S = Surface
• C = Color
• M = Mobility
Practical View of ENT 18

 Lump & Ulcer Examination

Inspection palpation
Lump 7S3P (STRC PF)3 ‫"ك‬
Ulcer 8S+FEM (TB)2 FEN 1$ 23 24

Lump examination
i. Inspection :-
 7S=Site , Size , S=Surface , Shape , Skin color ,Surrounding tissue,
Swelling movement ( with deglutition ,protraction of tongue ).

3P :- Pulsation , Pressure effect , Pulsation on cough .


ii. Palpation:-
 S3=Site , Size, Surface .
 T3 = Tenderness , Temperature , Translucency.
 R3 = Reducible , Relation to surroundings , Related LN .
 C3 = Color , Contour ,Consistency .
 P3 = Pulsation , Pressure effect , Pulsation on cough .
 F3 = Fixity , Fluctuation , Fluid thrill .

Ulcer examination :
i. Inspection :-
 8S = Site , Size , Shape , Surface , Sum , Skin , Structure seen
, Secretion.
 FEM = Floor , Edge , Margin .
ii. Palpation :-
 TB2 = Tender , Temperature , Base , Bleeding .
 FEN = Fixity , Edge , Node
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Nasal Examination
Exam in this order :-

1. Face
2. External nose
3. Collumala
4. Vestibule
5. Nasal cavity & nasopharynx
6. Sinuses
7. Oral cavity and oroharynx
8. Neck , ear , eye

Face Examination :-
4S

1. S1 = Symmetry
2. S2= Swelling
3. S3= Signs of inflammation and tumor ,
4. S4 = Surface features ( CRUST)
• C=Crust
• R=Rash
• U=Ulcer
• S=Skin features
• T=Thickness
Practical View of ENT 20

External Nose Examination :-

(7S5D )
7S = Swelling , Scar , Sinus fistula , Skin thickness & mobility ,
Signs of infection , Signs of malignancy , Salute sign ( allergic) .
D1 = Discoloration
D2 = Discharge
D3 = deformity
D4 = Diffuse edema
D5 = Defecated patency :- ( 3C ) :-
1. C= Collapsed valve
2. Cottle test
3. Cold spatula test

Collumella Examination :-

( COLUMella )

 C= Crust
 O= Over projection
 L= Low(ptosis) & broad
 U=Ulcer
 M = Malformed ( disturbed )

Vestibule Examination :-

( VEST…)
 V= Vestibulatis , furunclosis , ..
 E=Edema , Erosion
 S=Scar , Stenosis
 T=Tumor , Trauma
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Nasal cavity Examination :-


1) Mucoa ( PGD ) 53
• P=Pale mucosa or blue
• G=Gross erythm
• D=Dry
2) Septum ( PGD ) 53
• P=Perforation
• G=Growth
• D=Deviation
3) Leteral wall ( PGD ) 53
• P=Polyps
• G= Growth
• D=Discharge
4) Floor ( PGD ) 53
• P=Pus
• G=Granulation
• D=Defect ( cleft lip , palate )
5) Roof : - only seen during atrophic rhinitis
Nasophayrnx if mass

Sinuses Examination :-
Palpation , translucency , percussion ,
Practical View of ENT 22

Submandibular gland Examination


 Start :- I Want PERmission,CHAPERON, ASK And Do
Gently
 Proper Examination:-
Inspection :-
 From all direction
 Where is it (point it)
 6S (ON)2
 6S = Site , size, Shape ,symmetry , Skin over it
,Scar .
 (ON)2 = Oral cavity , Other mass, hypoglssal Nerve,
marginal mandibular Nerve .
 Other side
Palpation :-
 Bimanual
 (STRC PF)2 : see palpation of lump
 LAP : lymphoadenopathy
 Duct
 Temperature
 Compare Other side
 Lingual nerve :- 2/3 of tongue
 ENT exam
 Finish of Examination :-
THEY Want Helping Summary and Differential Diagnosis
Practical View of ENT 23

Parotid gland Examination


 Start :- I Want PERmission,CHAPERON, ASK And Do
Gently
 Proper Examination:-
Inspection :-
 From all direction
 Where is it (point of tenderness)
 6S (OF)2
 6S = Site , size, Shape ,symmetry , Skin over it
,Scar .
 (OF)2 = Oral cavity , Other mass, Facial nerve, Fistula
 Other side of
Palpation :-
 Bimanual
 (STRC PF)2 : see palpation of lump
 LAP : lymphoadenopathy
 Duct
 Temperature
 Compare with Other side
 ENT exam
 Finish of Examination :-
THEY Want Helping Summary and Differential Diagnosis
Practical View of ENT 24

C. Finish of Examination :-
( THEY Want Helping Summary and Differential Diagnosis )
They = Thanks to PT .
Want = Wash your hand
Helping = Help the patient to wear his/her clothes & Help the nurse
for arrangement .
Summary :- Summarized your case .
D.D :- Do differential & provisional diagnosis

Summarize the case:-


1. In chronological order, Hosp., drugs
2. Few, & well trusted sentences (3-5 sen.)
3. A concise accurate summary
4. Grasping the essentials of the case
5. Distilling the clinical data into its essence
Assessment with examiner

• Take the most important 1or 2 problems


• Discuss the DDs & professional Diag.

• DD for the case not for each problem


Practical View of ENT 25

Plan
 Your recommendations for management
 Diagnostic tests
 Therapy

Discuss Final Diagnosis

 Final Dx.
 Management
 Benefit
 Complication
Practical View of ENT 26

The Consent
( I Can Go Out And Pack ? Please Do Alternative Person "Any One Sir" )

 I= Introduce your self


 Can = confirm the Pt name
 Go = Gauge the starting point of pt  9:"#‫"ف <; ا‬4 7‫ ه‬/ $‫ ا‬., 1 2 ‫"ف‬4 7‫ه‬

 Out = Operation name and indication


 And Pack = Anatomy & Pathology (draw it )
 Please Do = Procedure details
 Preparation
 Anasthesia
 Steps & Stay in OT & ward
 Benefit %
 Complication %
 Effect on lifestyle
 Instruction
 Follow up
 Alternative= Alternative option even if disease untreated
 Person = Prognosis (outcome %)
 Any = Any question & ICE exploration
 One = On discharge advice :-
 Check pt understanding
 6D= drugs , Dressing , Diet, Discharge time , Date of
follow up , Don't work-water – strain .
 Sir = Summarization the information & close appropriately
Practical View of ENT 27

Breaking bad news


"Biopsy show cancer break this bad news "

BE ICE PLANS
32 2
 Barrier of tissue in your hand
 Emapthically
 Intriduce your self & your nurse
 Confirm pt name & Chaperone & Concern of pt
 Expectation of pt about biopsy result ( warring shot )
 Explan the bad news
 Plenty time for reaction (hand to shoulder , tissue for tear , body
languge )
 Plan of the pt future (ttt option , supportive side , find up & No)
 Lay person term . ‫ اخ‬
 Any question to answer
 Need to speek with his family (your telephone)
 Summarize the information
 Sure : Follow up plan , number for contact , source of
information & pt understand information and close
appropriately.
Practical View of ENT 28

Operative Notes
( PHASING – ‫)إد
ل‬
1. Patient name also remember - age (date of birth )
2. Hospital No ========================== Theater No
3. Anesthetist ===========================Types of anasthesia
4. Surgeon ============================- tech.nurse
5. Name of operation=====================date & time of OP
6. Indication of Op============== - preparation(antiHTN,Abs,diazip)
7. Gradating procedure
 Steps of special tool like microscope
 Finding
 Heamostasis ( cuttery , ties , gelfoam)
 Difficulties or intraOP complications
 Post Op plan (5F0 :-
1. Frequent observation of :-
(V/S, airway , swallowing , bleeding , vomiting)
2. Feed of fluid
3. Furthur:- antibiotics , analgesics
4. Finished discharge time
5. Follow up plan & instruction
Practical View of ENT 29

Discharge letter
(PHARCOMAS $ ‫)أورام‬

• Also remember
• P=Pt name Age ( date of birth )
• H=Hospital No Ward & room
• A=Admission date Discharge date
• C=Consultant Assistant
• O=Operation Investigation
• M=Medication Complications
• A=Advice Follow up
• S=Surgeon Anesthesiologist
Note :- Advice :-
 Time of work
 Dressing & suture
 Avoid
 Crust and bleeding
Practical View of ENT 30

How to do Flexible nasoendoscopy ?!

(ISGD 4S Thank )
1. I = I Want PERmission,CHAPERON, ASK And Do
Gently
2. S= Spray , Sniff in in 5 minute
3. G=Gloves , Gelly lubricant of lens , wire
4. D= Dominant hand for scope & other hand for lens
5. 4S :-
 S1= Slow insertion and direction
 S2= Say (EB-TV) :-
 E=EEE
 B=Breath
 T=Tongue out
 V=Valsalva & Muller maneuvers
 S3=Slowly withdraw scope and reassurance
 S4 = Show by draw , the epiglottis low
6. Thank :- ( THEY Want Helping Summary and Differential Diagnosis )
Practical View of ENT 31

Explain Diagnosis for Pt & Relative :-


(I Can Go Down Harry)
 I =Introduce your self
 C = Confirm
 G = Gauge
 D= Diagnosis
 H= History
 Anatomy
 Pathology
 Diagnostic test
 Treatment
 Alternative ttt
 Ensure :-
• Any question
• Follow up information
• Summary and close appropriately.