History taking in Otolaryngology
A comprehensive well taken history is half the job done. In majority of otolaryngological illness a reasonable diagnosis can be arrived at from the history alone.
Seeking the name of the patient:
A doctor should first introduce himself / herself to the patient with a handshake before seeking the name of the patient. Addressing the patient by his / her name would make the patient feel comfortable with the doctor. It will also ensure that the doctor is examining the correct individual with no mix up of patients. The religion of the patient can also be assumed by just asking the name of the patient. One need not openly seek history of religious belief from the patient.
Age of the patient:
Some of the ENT problems are age related. Adenotonsillar hypertrophy is commonly seen in young children. Nasopharyngeal angiofibroma is common in puberty. Congenital anomalies are noticed in early childhood. Malignancies are seen in patients above the age of 40 even though no age is immune to it. Pediatric cancers involving head and neck are also seen.
Sex of the patient:
Some of the diseases involving Ear / nose / throat have been known to show sex predilection. Nasopharyngeal angiofibroma is seen in males of puberty age group and is virtually non existent in females. Atrophic rhinitis and otosclerosis is common in females. Carcinoma larynx is more common in males while post cricoid malignancy is commonly seen in females.
It is very important to know the exact occupation of the patient. This history not only helps in arriving at a diagnosis but also gives an idea about his socio-economic status. The job of the patient per se could be the cause of the problem. For example, teachers, preachers, hawkers and singers who use their voice to the maximum are more likely to suffer from chronic laryngitis, vocal nodule etc. People working in wood industries, petroleum refineries are more prone to develop malignancy of nose and sinuses. People working in noisy environment are prone to develop noise induced hearing loss. Treatment policy of the illness could change as per the occupational requirements of the patient. If a patient’s occupation depends on voice then irradiation is preferred to total laryngectomy in patients with laryngeal cancer.
This is another important history that needs to be taken. Some of the diseases / disorders involving Ears / Nose / Throat are location specific. For example, rhinosporidiosis is endemic in certain states of India. People living in damp atmosphere are prone to develop otitis externa or otomycosis frequently. Proper record of postal address of the patient is essential for proper follow-up
Patients invariably not aware of the clinician’s needs and hence have a tendency to beat around the bush. It is the duty of the physician to be patient and pull out the relevant history from the patient’s mouth. All complaints should be documented in the exact words of the patient and in a chronological order. Example: Ear discharge – 2 years Hearing loss (side) – 1 year Head ache – 7 days Fever – 2 days If the patient says that all the complaints started at the same time then the more severe one should be written first.
History of present illness:
This should be documented in patient’s own language as far as possible. Each and every complaint should be properly analyzed. Focus should be on the mode of onset; severity of the complaint and laterality should also be sought. In the case of ear discharge the patient should be asked how the discharge started, what made it to start because it would bring out the history of acute otitis media or history of trauma. Severity of complaint should also be sought as it gives the examiner vital information on whether it needs urgent intervention or not. Leading questions should always be avoided. Negative history could be very useful. This can be illustrated aptly by the following scenario, perforation of nasal septum without history of surgery on nasal septum would suggest heavy metal poisoning or chronic granulomatous lesion inside the nasal cavity.
The diseases patient had suffered prior to this illness should also be narrated along this history in a chronological order. The treatment details and duration of treatment should also be documented under this heading. Operative procedures if any performed should also be detailed. Treatment history may be relevant for example if the patient is on antihypertensives like methyl dopa then there could be associated stuffy nose. In this scenario instead of attempting a nasal decongestant, it is prudent to change the antihypertensive that does not cause nasal stuffiness. Drug history is also a must. If the patient gives history of treatment with streptomycin then it could account for sensorineural hearing loss.
Some diseases affecting the ear / nose / throat have a tendency to run in families. Family history is a must in patients with deafness in early childhood, epistaxis, nasal allergy etc.