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

M HOSPITAL

DISCHARGE CARD HEAD OF UNIT:- DR NILAM SATHE

NAME: SANJEEVKUMAR SURESH SINGH AGE: 16 YRS SEX: MALE

RES: VILLAGE SITUHAR POST – GOSPUR, BLOCK PRATAPGANJ WARD NO 3, PRATAPGANJ- 852215, Bihar
IPD NO – 24/7269 PH NO.- 7700016585 OPD NO- 23/20250
Date of admission: 12/2/2024 Date of surgery: 13/2/2024 Date of discharge: 14/2/2024

Diagnosis: Right inactive mucosal chronic otitis media with Right mild to moderate conductive hearing loss with left
mild conductive hearing loss with no evidence of any complications in an o/c/o left Tympanoplasty
Surgery: Right type I Tympanoplasty under Local anaesthesia and intravenous sedation d/b Dr Davish a/b Dr Ankit
c/s/b Dr Juilee on 13/2/2024
HOPI- C/o– Bilateral ear discharge since childhood, insidious in onset, gradually progressive ,mucopurulent, non foul
smelling, non blood stained, associated with upper respiratory tract infection, relieved with medications
-H/o eardrops reaching throat present
-H/o decreased hearing, such that patient prefers left ear for telephonic conversation
-No H/o giddiness/tinnitus
-No H/o Ototoxicity/loud noise exposure/trauma
-No H/o Facial asymmetry
-No H/o pre or post aural swelling
-No h/o fever with neck rigidity/ LOC/ Seizure
-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 Conductive hearing loss
Left : moderate to mild conductive hearing loss
Xray Mastoid – Right – Sclerosed
Left – Sclerosed

OT NOTES – Right type I Tympanoplasty under Local anaesthesia and intravenous sedation d/b Dr Davish a/b Dr Ankit
c/s/b Dr Juilee on 13/2/2024
1)Patient taken under local anaesthesia and intravenous sedation
2)Parts painted and draped under all aseptic precautions
3)Right post aural William Wilde’s incision taken.
4)Temporalis fascia graft harvested.
5)Deep periosteal incision taken.
6)Posterior meatotomy done.
7)Examination Under microscope, central large perforation present
8)Margins freshened and edges undermined
9)12’o clock and 6’o clock Incision taken, and incision for anterior tucking done and, tymapnomeatal flap elevated.
10)Middle ear entered
11)Handle of malleus seen. Incudostapedial joint visualised, mobile.
12)Temporalis fascia Graft placed under handle of malleus .
13)Anterior tucking done
14)Tymapnomeatal flap reposited
15)Gelfoam placed at the edges of perforation graft assembly
16)External auditory canal packed with medicated gelfoam.
17)Suturing done in layers
18)Sterile mastoid dressing given.
19)Immediate post op uneventful
20)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