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    This document contains a template for recording patient information and examination findings for the Department of ENT (Ear, Nose, and Throat) at Gandhi Medical College, Bhopal. The template includes sections for documenting a patient's registration details, history, general and ENT specific examination findings, differential diagnosis, investigations, treatment, and case summary. Examination sections are included for the ear, nose, throat, neck, and related structures.

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    Ent Logbook

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    This document contains a template for recording patient information and examination findings for the Department of ENT (Ear, Nose, and Throat) at Gandhi Medical College, Bhopal. The template includes sections for documenting a patient's registration details, history, general and ENT specific examination findings, differential diagnosis, investigations, treatment, and case summary. Examination sections are included for the ear, nose, throat, neck, and related structures.

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    FORMAT FOR CASE RECORDING

    Original Title

    ENT LOGBOOK

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    This document contains a template for recording patient information and examination findings for the Department of ENT (Ear, Nose, and Throat) at Gandhi Medical College, Bhopal. The template includes sections for documenting a patient's registration details, history, general and ENT specific examination findings, differential diagnosis, investigations, treatment, and case summary. Examination sections are included for the ear, nose, throat, neck, and related structures.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    2K views9 pages

    Ent Logbook

    Uploaded by

    vishalzenia
    This document contains a template for recording patient information and examination findings for the Department of ENT (Ear, Nose, and Throat) at Gandhi Medical College, Bhopal. The template includes sections for documenting a patient's registration details, history, general and ENT specific examination findings, differential diagnosis, investigations, treatment, and case summary. Examination sections are included for the ear, nose, throat, neck, and related structures.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 9

    DEPARTMENT OF ENT

    Gandhi Medical College, Bhopal

    Registration/Case no. Date


    RSO 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 Left
    Preauricular region

    Pinna

    Postauricular region
    (including mastoid)
    EAC

    TM
    DIAGRAM: Right Left

    Right Left
    Tuning fork tests

    *Rinnes test

    *Webers test

    *ABC
    Eustachian tube
    (Valsalva maneavur)

    Facial nerve

    Spontaneous
    Nystagmus

    Rombergs test
    Fistula test

    Caloric test

    Gait assessment

    NOSE
    Nasal profile:

    Nasal passages:

    Patency:

    Olfaction:

    Palpation:

    Anterior rhinoscopy
    Septum:

    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:

    NECK
    Lymph 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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