OTORHINOLARYNGOLOGY CASE HISTORY

Krishnakumar akhil vishnu

Group 24
4th course
6th faculty
General medicine
 ACUTE MAXILLARY SINUSITIS
PERSONAL DATA
Name: Thomas C.P
Occupation: CDA Employee
Age: 66
D.O.B: 1954/11/18

HISTORY
Main complaints: Pain over cheek and forehead- 1year
HISTORY OF THE PRESENTING ILLNESS:
Pain: According to the patient, he was alright a уear back when he started
developing pain over the cheeks and forehead, which developed gradually and
slowly so much so that he started to have severe pain on bowing his head
down for sajda during prayers. He got some medical treatment off and on with
little improvement. Now he has severe pain over the cheeks for last 15 days for
which he agreed to get admitted at capital hospital.

PAST HISTORY: Patient has past history of maxillary sinus wash but details are
not available.

FAMILY HISTORY: He is orphan and unmarried

PERSONAL HISTORY: Smoker (1 рack per day for last 20 years) with normal
bowel habits.

DRUG HISTORY: had been taking antibiotics for sinusitis off and on.No history
of any drug allergy.
SOCIOECNOMIC HISTORY: belongs to lower middle class.

GENERAL PHYSICAL EXAMINATION:

An old man sitting anxiously in bed, well oriented time, place and person.
Anaemia -absent
Jaundice -absent
Clubbing-absent
Сyanosis-absent
Palpable Nodes-absent
Temperature- Afebrile
Pulse-80 beats per min. Regular
BP- 140/90 mmHg

SYSTEMIC EXAMINATION:
Resp System: NAD
CVS: NAD
CNS: NAD
GIT: NAD

E.N.T EXAMINATION:
NASAL EXAMINATION:
Inspection: Anterior Rhinoscopy:Swollen inferior Turbinates with some
mucopus along the nasal floor
Posterior Rhinoscopy: NAD
Palpation: Tenderness over cheeks.

EXAMINATION OF THROAT
Poor oral hygiene
Gingivitis

EXAMINATION OF EARS
Inspection: Surrounding area, pinnae, EAM, EAC, T.M normal.
Palpation: NAD
Hearing Test: Hears forced whisper at ear level.
Tunning Fork Test:
Rinne’s : Positive on both sides
Weber : Central
ABC : Reduced by 5 sec both side

PROVISIONAL DIAGNOSIS:
Acute maxillary sinusitis
with gingivitis and mild SNHL

INVESTIGATION:
CP: Within permal limits.
ESR: 05 mm within 1st hr.
Renal Profile: Within Nomal Limis
Blood Sugar (Random): 90 mg / Dl
X-RAY PNS:
Rt. Max. Sinus is Hazy, Lt. hazy but less compared to Rt.
Both Middle and inf. turbinates Swollen with obliteration of both nasal spases.

X-RAY : Chest normal.

TREATMENT:
MEDICAL TREATMENT:
Inj. Ampicillin 500 mg I / V TDS
Hyposine nasal spray tds
Steam inhalations tds.
Tab. Flagyl 400 mg tds.
Gargalen dil. mouth wash.

Drugs Advised by Medical Department

Tab. Lexillium 3 mg 1 x HS
Tab. Сapace 25 1/2 x BD

RESULT AND FOLLOW UP:

Patient was much relieved of his symptoms at the time of discharge and a
check X-Ray revealed improvement