DEPARTMENT OF E.N.T. AND HEAD AND NECK SURGERY, K.E.

M HOSPITAL

DISCHARGE CARD HEAD OF UNIT:- DR NILAM SATHE

NAME: AISHWARYA ROY LAXMI RAJMANI PAL AGE: 23 YRS SEX: FEMALE

RES: VILLAGE, NANDAIPUR POST PUREDHANA, PURE DHANA, PRATAPGARH, UTTAR PRADESH 230134, Uttar Pradesh
IPD NO – 24/6036 PH NO.- 7080613344 OPD NO- 24/12813
Date of admission: 5/2/2024 Date of surgery: 6/2/2024 Date of discharge: 7/2/2024

Diagnosis: Left inactive mucosal chronic otitis media with Right mild to moderate mixed hearing loss and left mild to
mixed hearing loss with no evidence of any complications
Surgery: Left type I Tympanoplasty under Local anaesthesia and intravenous sedation d/b Dr Anjali Dr Davish a/b Dr
Ankit on 6/2/2024
HOPI- C/o– left ear discharge since 2-3 years, insidious in onset, gradually progressive ,mucopurulent, non foul
smelling, non blood stained, associated with upper respiratory tract infection, partially relieved with medications
-H/o eardrops reaching throat present
- H/o left ear decreased hearing, insidious in onset, gradually progressive, such that patient prefers right ear for
telephonic conversation
-No H/o giddiness/tinnitus
-No H/o Ototoxic drug use/loud noise exposure/trauma
-No H/o Facial asymmetry
-No H/o pre or post aural swelling
-No h/o headache with altered sensorium / projectile vomiting
-No H/o nasal obstruction /recurrent rhinitis
-No H/o Recurrent sore throat
-No H/o of any other ENT complaints
-no H/o MMI/MSI
-No h/o HTN/DM/BA/TB/TBC

Clinical Examination:
GENERAL: Fair, conscious oriented
EAR: Right Left. TFT Right Left

PRE AURICULAR 256hz

PINNA 512hz
POST AURICULAR 1024hz
EAC Weber
TM ABC

NO FP/MT/Nyst
NOSE : Air blast Equal, No sinus tenderness
ARS- within normal limits
THROAT : Mouth opening adequate
Posterior pharyngeal wall – within normal limits

INVESTIGATIONS:
PTA: Right – mild to Moderate mixed hearing loss
Left – mild to moderate mixed hearing loss
Xray Mastoid – Right – Pneumatic
Left – Pneumatic

OT NOTES – Left type I Tympanoplasty under Local anaesthesia and intravenous sedation d/b Dr Anjali Dr Davish a/b
Dr Ankit on 6/2/2024
-Patient taken under local anaesthesia and intravenous sedation
-Parts painted and draped under all aseptic precautions
-left post aural William Wilde’s incision taken.
-Temporalis fascia graft harvested.
-Deep periosteal incision taken.
-Posterior meatotomy done.
-Examination Under microscope, anterior perforation present
-Margins freshened and edges undermined
-12’o clock and 6’o clock Incision taken and incision for full cuff taken, and tymapnomeatal flap elevated.
-Middle ear entered
-Handle of malleus seen. Incudostapedial joint visualised, mobile.
-Temporalis fascia Graft placed under handle of malleus .
-Gelfoam placed at the edges of perforation graft assembly
-External auditory canal packed with medicated gelfoam.
-Suturing done in layers
-Sterile mastoid dressing given.
-Immediate post op uneventful
-Weber to operated ear

COURSE IN THE WARD: Inj. Advent 1.2g IV BD x 3 days

ADVICE ON DISCHARGE:
TREATMENT:
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FOLLOW UP IN E.N.T. OPD 107 – MON /WED/FRI AT
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FOR SR / DRESSING/ FOLLOW UP

HOUSEMAN REGISTRA2R