ENT (Otorhinolaryngology) Clinical Case Proforma

For Ward Presentation — Department of ENT

| Date:

1. Identification & Presenter Details

Patient Name

Age / Sex

IPD / Bed No.

Occupation

Address

Date of Admission

Presenting Student & Roll No.

History given by

Patient Attendant

2. Chief Complaints

Tick all that apply. Specify side involved (Right/Left/Both) for each.

✓	Chief Complaint	Side	Site	Duration (since)
	Ear pain / discharge
	Hearing loss
	Sore throat
	Nasal obstruction
	Nasal discharge
	Hoarseness of voice
	Vertigo / tinnitus
	Neck swelling
	Difficulty swallowing
	Epistaxis / foreign body sensation
	Other:

3. History of Present Illness

Mode of Onset

Acute onset Gradual / progressive onset Following upper respiratory infection Following trauma / foreign body Recurrent episodes Other:

Character of Pain / Key Symptom — SOCRATES

To be filled whenever ear/throat pain is a chief complaint.

S — Site
O — Onset
C — Character
R — Radiation
A — Associated symptoms
T — Timing
E — Exacerbating / relieving factors
S — Severity (0–10)

4. Past, Personal, Family & Treatment History

5. General Physical Examination

Build

Nutrition

Consciousness

Vitals

PR (/min)

BP (mmHg)

RR (/min)

Temp

SpO2 (%)

RBS

GCS

6. ENT Examination

A. Ear Examination

Structure	Right Ear	Left Ear
Pinna & peri-auricular area
External auditory canal
Tympanic membrane

Tuning Fork Tests

Test	Right Ear	Left Ear
Rinne's test
Weber's test
ABC test

B. Nose Examination

Anterior rhinoscopy
Nasal airway patency
Paranasal sinus tenderness

C. Throat / Oral Cavity Examination

Oral cavity & oropharynx
Indirect / video laryngoscopy

D. Neck Examination

7. Systemic Examination

8. Investigations

✓	Investigation	Findings
	Pure tone audiometry
	Tympanometry
	Nasal endoscopy
	X-ray / CT paranasal sinuses
	CT temporal bone
	Flexible laryngoscopy
	Throat swab culture
	Hb / TLC / platelet count
	Other:

9. Diagnosis

Provisional Diagnosis

Differential Diagnosis

10. Treatment Plan

Conservative / medical management Ear syringing / local ear care Operative management planned Analgesia / antibiotics Speech / hearing therapy referral Follow-up plan

11. Summary

Auto-generated from ticks & entries above, in the fixed order of the sections — edit freely before presenting.

Presenting Student's Signature

Countersigned by Faculty / Resident

ENT Clinical Case Proforma — for teaching purpose · not a legal medical record

Sign	Absent	Present	Details (site / grade)
Pallor
Icterus
Cyanosis
Clubbing
Lymphadenopathy
Edema

System	Normal	Abnormal	Details
Cardiovascular System
Respiratory System
Central Nervous System