7.

DIAGNOSIS STEPS

History

1. Greet / introduce yourself in a polite manner

2. Ask the patient's identity:

• Name: Mr. Y

• Age: 60 years

• Residence : -

• Occupation : -

3. Ask the main complaint: Decreased hearing in both ears

4. Ask for more details related to the main complaint, for example,

a) Duration of complaint: 6 months

b) If there is a hearing loss, ask whether the complaint is in one or

both ears

c) Complaints arise suddenly or gain weight gradually

d) Ask whether the complaint is spread to other parts such as:

mastoid area, chin, cheeks

e) Ask if the disturbance is more pronounced in a noisy place or a

quieter place

f) Are there other accompanying symptoms such as: buzzing ears

(tinnitus), spinning dizziness, ear pain, fever, headache.

5. Ask about the same disease you suffered before

6. Ask about the history of other diseases such as diabetes,

hypertension, thyroid, severe influenza and TB,

 7. Ask if there is a history of head trauma, slapped ears, acoustic

trauma, exposure to noise,

8. Ask about treatment history: use of ototoxic drugs, use of drugs

for 6 months

9. Ask about the history of the same disease in the family /

environment.

Physical examination

1. General:

• General circumstances: GCS (composmentis, delirium)

• Examination of vital signs: blood pressure, pulse, breathing, body

temperature

2. Inspection of the external ear

• Are there any swelling, macrotia, microtia, redness

3. Palpate the external ear

• Pressing with the index finger on the right hand on the front and back

of the ear to assess any abnormalities in the ear

• Pulling the auricle to assess the presence or absence of pain

4. Otoscopy:

• Use the ear speculum to assess: the state of the ear canal, the state of

the eardrum

5. Hearing examination:

• Whisper test: to assess the quantity and quality of deafness

 • Tuning fork test:

- Hearing line test

- Weber test

- Rinne test

- Schwabach test

Supporting investigation

1. Electronistagmography: to help examine the possibility of injury or

problems in the inner ear, brain, or nerves that connect the two

2. CT Scan: to show anatomical structural abnormalities

3. MRI

4. Laboratory tests: to check for possible infections of viruses, bacteria,

autoimmune diseases.

Referensi :

 Penuntun clinical skill lab (CSL), Blok system indera khusus

angkatan 2017 tahun 2019, fakultas kedokteran UMI.

 Utama Hendra dkk, 2018, Buku ajar ilmu kesehatan THT kepala

dan leher, Edisi 7, Badan penerbit FK UI: Jakarta.