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Case presentation

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Case presentation

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  1. Case presentation

  2. Name – Mr. Boranna • Age – 40yrs • Sex- male • Occupation- coolie • Add - chalakere

  3. Chief complaint • Bilateral nasal obstruction – 4 months • More on rt side

  4. History of presenting illness • B/l nasal obstruction -4 months • More on rt side • Insidious in onset , intermittent, constant • Ass with repeated episodes of cold with nasal discharge which is watery in consistency • Reduces on medication

  5. Past 15 days days nasal obstruction is continuous • h/o post nasal drip + • h/o reduced sense of smell+ • h/o snoring + • h/o change of voice +

  6. No h/o sneezing • No h/o facial pain or headache • No h/o tinnitus , ear pain or discharge • No h/o foul smell from nose or foul taste • No h/o watering of eyes , nose or throat • No h/o sneezing • No bleeding from nose • No h/o trauma to face/nose • No h/o dryness of nose

  7. Past history • Not a known case of DM/hypertension • No h/o asthma / drug allergy /TB drug/ bleeding disorder • h/o RTA 4 months back with trauma to foot , no trauma to face or head • No h/o surgery or hospitalization

  8. Family history • No h/o similar complaints in family • Patient is married and have 2 children

  9. Personal history • Mixed diet • B/B- regular • Sleep- undisturbed • Appetite- good • No habits

  10. General examination • Patient is conscious , cooperative • Moderately built and nourished • Pallor- BP- 130/80mmhg • Icterus- pulse-80beats/min • Clubbing- afebrile • Cyanosis- • Lymphadenopathy- • Edema-

  11. Systemic examination • CVS- S1S2 heard , no murmur • R/S- b/l NVBS+ • P/A- soft , no organomegaly • CNS- no focal neurological deficit

  12. ENT examination • Nose- • External appearance • Root , dorsum , tip, supratip, ala , columella, vestibule- normal

  13. Anterior rhinoscopy examination • Septum is in midline, no deviation • Bilateral pale ,polypoidal • mass filling the nasal • cavity On probing it is insensitive to touch Doesnot bleed on touch Can be probed all around except superolaterally On rt side only a part of inf turbinate can be visualized, lt side turbinate not seen

  14. Cold spatula test – no misting seen on rt side • PRE – normal • PNS- no tenderness

  15. Ear – bilateral normal • Throat – oral cavity - normal • orophaarynx- normal • Neck - normal

  16. Probable diagnosis • Bilateral ethmoidal polyps