KHARKIV NATIONAL MEDICAL UNIVERSITY
OTORHINOLARYNGOLOGY DEPARTMENT
Head of the
Otorhinolaryngology Department
A. Lypur, MD, associate professor
Teacher
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STUDENT’S CASE HISTOR
Patient____________________________________________, _______-year-old
Work place_______________________________________________________
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Clinical diagnosis:__________________________________________________
Main diagnosis: ____________________________________________________
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Complications______________________________________________________
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Additional diagnosis:
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Student
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______________faculty
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First, second name
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Kharkiv
Complaints
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Medical history: considers himself ill during the __________ when the above
complaints have arisen.
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Life history: Virus Hepatitis_____, Tuberculosis____, Diabetes mellitus
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Venereal disease _____
Allergic history without features. Intolerance ________________
There was no blood transfusion and its components. History of life without features.
Living, working and living conditions are satisfactory. Transferred diseases,
operations
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Heredity is not burdensome. Habits: smoking, addiction to alcohol.
Objectively: the patient's overall condition is satisfactory, moderate, severe.
Proper constitution, elevated, good, satisfactory nutrition. Skin and visible mucous
membranes of normal color, hyperemic, pale, cyanotic, icteric. No rash, erythematous,
papular, bullous on _________________. Peripheral lymph nodes are not enlarged,
enlargement of angular and maxillary, inguinal lymph nodes. Musculoskeletal system
without visible pathology. Lungs auscultation: vesicular breathing, weakened, hard
breathing, no wheezing, scattered, dry, wet, (left, right). Pulse ___ beats per minute,
satisfactory qualities, heart tones pure, muffled, rhythmic, arrhythmic, noises are not
heard, blood pressure __ / __ mm Hg The abdomen is soft, painless, abdominal organs
without visible pathology, tapping in the lumbar region is painless on both sides.
Neurological status: no features. Physiological departure is normal.
ENT status: The outer nose is not deformed. Palpation and percussion of projection
points of the nasal sinuses are painful, painless. The mucous membrane of the nose:
pink, hyperemic, pale, moist, dry, swollen, deviation of the nasal septum. Nasal
breathing free, complicated, persistent hypertrophy of the inferior nasal turbinates. In
the nasal passages (left, right) mucous, mucous-purulent discharge. With posterior
rhinoscopy without pathology, the posterior ends of the inferior nasal turbinates are
enlarged, hypertrophy of the nasopharyngeal tonsil __ stage.
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The mucous membrane of the pharynx is pink, hyperemic, pale, moist, dry.
Hypertrophy of lymphoid tissue in the form of granules on the back wall of the
pharynx, hypertrophy of the posterior pillar, hypertrophy of the palatine tonsils ____
stage.
Palatine
tonsils
with
scar
change,
soldered
with
pillars._________________________________________________
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The larynx mucosa: pink, hyperemic, pale, moist, dry, swollen. Vocal folds are evenly
mobile during phonation and breathing, mobility restrictions (left, right), edema,
infiltration (left, right) of the vocal fold, vestibular vocal folds (left, right), epiglottis.
Voice
function
is
not
compromised
(decreasing,
lost).________________________________________________________________
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Right ear (AD): The external auditory meatus is wide, narrowed by infiltration,
swelling of the skin, clean, covered with mucous-purulent secretions, cholesteatomic
masses. Tympanic membrane is pearl-gray color, hyperemic, moving, retracted,
extended.
Perforation
is
marginal,
central,
total,
subtotal
in
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Distinctive points are visualizating well, not visible. Mucous membrane of tympanic
cavity is pink, hyperemic, pale, wet, dry, swollen, granulation, polyp
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The patency of the auditory tubes ___ stage. Hearing: whispering ____ m.
speaking____ m.
Left ear (AS): The external auditory meatus is wide, narrowed by infiltration, swelling
of the skin, clean, covered with mucous-purulent secretions, cholesteatomic masses.
Tympanic membrane is pearl-gray color, hyperemic, moving, retracted, extended.
Perforation
is
marginal,
central,
total,
subtotal
in
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Distinctive points are visualizating well, not visible. Mucous membrane of tympanic
cavity is pink, hyperemic, pale, wet, dry, swollen, granulation, polyp
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The patency of the auditory tubes ___ stage. Hearing: whispering ____ m.
speaking____ m.
PRELIMINARY DIAGNOSIS
(justify preliminary diagnosis using complaints, history, review)
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Scheme of examination (make a scheme of examination using laboratory and
instrumental methods)
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RESULTS OF ADDITIONAL RESEARCH METHODS
Blood test
Urinary test
Date___________________________
Date______________________
RBC 10* /л___________
Hb g/l_______________________
WBC 10*9/л_____________
PLT 10*9/л____________
GRAN:
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LYM_________________%
MON__________________%
EOS_________________%
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Conclusion ___________________
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count _______________
color__________________
transparency _____________
consistence______________
PH____________________
protein__________________
RBC_____________
WBC______________
bacteries________________
mucus ___________________
Conclusion ____________________
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12
Biochemical tests of the liver
Blood group, Rh factor
Data___________________________
Data________________________________
Total bilirubin__________
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Connected _____________
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Free ______________
RW-test
ALT/AST______________________
Data___________________________
Alkaline phosphatase ____________
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Timol
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B - lipoproteins _____________
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Conclusion___________________
ECG
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Data_______________________________
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Other methods
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Hearing
Right ear (AD)
Wispering
Speaking
С128(П=90сек.)
С128(П=50сек.)
С2048(П=40сек)
Rinne
Veber
Federiche
Left ear (AS)
Wispering
Speaking
С128(П=90сек.)
С128(П=50сек.)
С2048(П=40сек)
Rinne
Veber
Federiche
Appellation (-о-о-о-) – air conduction, (-х-х-х-) – bone conduction.
Conclusion_____________________________________________________________
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Tympanometry: type А, type В, type С
Conclusion_____________________________________________________________
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Vestibular system
Right side
Tests
Left side
Subjective feelings
Spontaneous nystagmus
Finger-nose test
Finger-finger test
Vodak-Fisher test
Stability in the Romberg pose
Straight walk
Flang walk
Adiadokhokinez
Press test
Conclusion_____________________________________________________________
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DIFFERENTIAL DIAGNOSIS
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FINAL СLINICAL DIAGNOSIS (Diagnosis clinika)
(to substantiate the final diagnosis taking into account all complaints, histories,
objective study data, using ancillary research methods, make a diagnosis based on
modern clinical classification of the disease (major, complication of major,
concomitant)
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COMPLICATIONS
(list all possible complications of the disease)
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Etiology and pathogenesis of the disease
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TREATMENT AND PREVENTION
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Prognosis
(regarding recovery, life, work capacityі)
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DISEASE JOURNAL
Data
The condition of the patient
Treatment
Literature
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Teacher's
note_____________________________________________________
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Mark_____
SIGNATURE OF TEACHER:_________________