Chronic suppurative otitis media A model case sheet by drtbalu

Chronic suppurative otitis media A model case sheet by drtbalu (CSOM model case sheet by drtbalu) Chronic suppurative otitis media: Case sheet lay out: Name: Age: Sex: Occupation:  The name of the patient, age and sex should be clearly written. A detailed occupation history should also be taken because of the propensity for certain occupation to cause disorders in hearing (i.e. like working in noisy environment which could cause noise induced sensorineural hearing loss). Chief complaints: Under this heading the following questions must be put and the answers given by the patient diligently noted in their own language. (No medical terminology should be used here). 1. Ear discharge : Presence / absence, ? ear is affected, duration 2. Ear pain: Which ear is affected ? Duration ? 3. Hard of hearing: Which ear? Duration? ? Assocaited with tinnitus

History of presenting illness: Under this heading the patients complaints should be described in the chronological order as presented by the patient. Ear discharge: ? ear / duration Onset / progressive ? Quantity of discharge: scanty / profuse ( Discharge from unsafe ears are usually scanty, while discharge from safe ears are profuse. Profuse discharge sometimes may also be due to subdural abscess ) Characteristics of discharge: This includes color of the discharge and smell emitted by it. If the discharge is yellowish - it could be only pus If the discharge is white - the discharge is termed mucoid (common in acute otitis media) If the discharge is blood stained it is termed serosanguinous in nature. This type of discharge is commonly seen in acute suppurative otitis media, presence of  granulation tissue, myringitis granulosa etc. Aggravating / relieving factors if any should be noted. Hard of hearing: ? Duration Onset: Progressive / stationary  The patient's ability to hear well in noisy environment "whispering Pectoriloquy " if any should be noted. This is a classic feature seen in otosclerosis. Aggravating / relieving factors if any should be documented. If hard of hearing is associated with tinnitus it indicates sensorineural deafness. Ear ache: Ear ache if any should be documented. Aggravating / relieving factors if any should be noted. In otitis externa ear ache is more when the patient is chewing food. Past History:

History of head ache: This is positive in cases with CSOM associated with intracranial complications.