Clinical Medicine Year 2 DCM 2203: Ear, Nose and Throat Care Sub-topic 1.1: Clerkship in ENT
ENT history taking is a focused, respectful conversation that helps a clinician understand a patient’s ear, nose, throat, voice, swallowing, balance, hearing and head-and-neck concerns. A good history describes what the patient experiences, when it began, how it has changed, its effect on daily life and the warning features that may need urgent assessment. It guides examination and investigations; by itself, it does not confirm a diagnosis.
Learning objectives
By the end of this guide, the learner should be able to:
- Open and conduct an ENT consultation with clear communication, consent and attention to privacy.
- Take a chronological history of presenting complaints and explore symptoms in the ear, nose, throat, mouth, voice and neck.
- Ask focused questions about laterality, onset, duration, progression, associated symptoms and functional impact.
- Identify features that need emergency assessment or prompt referral, while following local pathways.
- Summarise and document an accurate, relevant history without jumping prematurely to a diagnosis.
A practical structure for the interview
Begin broadly, then focus. Let the patient explain the main concern in their own words before using targeted questions. For each symptom, establish its onset, duration, course, site, side, severity, character, triggers, relieving factors, associated symptoms, previous episodes and treatment tried. The amount of detail depends on the presentation and the patient’s condition.
1. Establish the context
Confirm the patient’s identity using local policy, age, source of the history and whether an interpreter or caregiver is helping. Record reliability only when relevant and explain why a detail is uncertain.
2. Record the main concern
Write the main complaint or complaints in the patient’s words where possible, with the duration and side. List multiple complaints in chronological order.
3. Explore the story
Clarify the timeline, pattern, severity, progression, associated symptoms, triggers, previous episodes, treatment and response. Ask what has changed today.
4. Add relevant background
Review previous ENT and general illness, procedures, medicines, allergies, family history, work and environmental exposures, tobacco or alcohol use, and relevant system symptoms.
5. Assess function and risk
Ask how the problem affects hearing, communication, sleep, eating, swallowing, balance, school, work and social life. Screen for red flags throughout the interview.
6. Summarise and check
Reflect the key details back to the patient, invite correction and ask whether there is anything important that has not been covered.
Before asking detailed questions
- Introduce yourself and your role; confirm how the patient would like to be addressed.
- Explain the purpose of the questions and obtain permission to proceed. Preserve privacy and confidentiality.
- Use a quiet, well-lit setting where possible. Face the patient, speak clearly and at a suitable pace, and check whether hearing aids, glasses, a communication aid or an interpreter are needed.
- Use open questions first: “What has been troubling you?” and “Tell me what happened next.” Follow with specific questions without leading the patient.
- For a child or a person who cannot give the full history, identify the caregiver or other source, obtain the patient’s own account as appropriate, and distinguish what was observed from what was reported.
- Respond calmly to distress, pain, embarrassment or communication difficulty. Pause or prioritise immediate comfort and safety when appropriate.
Presenting complaint and history of the present illness
Use chronology, not a list of disconnected symptoms
Document when the symptom started and what was happening at the time. Clarify whether it started suddenly or gradually, whether it is continuous or intermittent, and whether it is improving, worsening, recurring or fluctuating. Record which side is affected, whether one or both sides are involved, and whether symptoms have spread or changed. Ask about possible triggers such as an upper respiratory infection, water exposure, pressure change, loud noise, trauma, dental problems, new medication or an allergic exposure.
For pain, a familiar structure such as SOCRATES can help: Site, Onset, Character, Radiation, Associated symptoms, Timing, Exacerbating or relieving factors, and Severity. It is a prompt, not a substitute for listening; use only the parts that fit the patient’s complaint.
Focused questions by symptom area
| Area or symptom | Focused questions to consider | Functional or associated impact |
|---|---|---|
| Ear pain (otalgia) | Which ear? When did it start? Is it constant or episodic, sharp, dull, burning or throbbing? Does it radiate to the jaw, teeth or throat? Is it affected by touching the outer ear, chewing or swallowing? Any trauma, water exposure, discharge or fever? | Sleep, eating, school or work; pain with jaw movement; dental or throat symptoms that may suggest a source outside the ear. |
| Ear discharge (otorrhoea) | Which side? When did it begin? How much, how often, and what colour or consistency? Is it foul-smelling, blood-stained or watery? Did pain or hearing change occur before or after it? Any ear instrumentation, injury, surgery or swimming? | Fever, severe pain, dizziness, hearing change or facial weakness; effect on hearing aids and daily activities. |
| Hearing difficulty | Sudden or gradual? One ear or both? Stable, fluctuating or progressive? Any difficulty understanding speech, especially in noise? Tinnitus, ear fullness, pain, discharge, dizziness, infection, trauma, loud-noise exposure or relevant medicines? | Communication, learning, speech and language development in a child, safety, work and social participation; use and benefit of hearing aids. |
| Tinnitus | Is there a ringing, buzzing, humming or other sound? One side or both? Constant or intermittent? Does it pulse in time with the heartbeat? When did it begin, and is it associated with hearing change, dizziness, pain or medicines? | Sleep, concentration, mood, distress and ability to function. Ask about the patient’s level of concern and support needs. |
| Dizziness or imbalance | Ask the patient to describe the sensation in their own words. Is it spinning, faintness, unsteadiness or difficulty walking? How long does each episode last? Is it triggered by movement or position? Nausea, hearing change, tinnitus, headache, weakness, numbness, double vision or falls? | Walking, transfers, driving or other safety-sensitive tasks; falls, vomiting, hydration and ability to manage at home. |
| Nasal obstruction or discharge | One side or both? Constant or intermittent? Any clear, thick, purulent, bloody or foul-smelling discharge? Sneezing, itching, reduced smell, facial pressure, dental pain, allergy, fever, trauma or a foreign body possibility? | Sleep, smell, taste, breathing, feeding in infants, voice quality and ability to work or study. |
| Epistaxis (nosebleed) | Which nostril or both? When did it start, how often and for how long? Is bleeding ongoing? What seemed to trigger it? Any injury, nose picking, medicines that affect bleeding, easy bruising or previous episodes? | Estimated amount, faintness, weakness, breathing or swallowing blood, and known bleeding disorders. Do not delay emergency assessment for severe or uncontrolled bleeding. |
| Sore throat or painful swallowing | Onset and duration? Pain on swallowing or difficulty getting food or liquids down? Solids, liquids or both? Any fever, drooling, change in voice, mouth ulcers, tonsil symptoms, choking, regurgitation or neck swelling? | Ability to swallow saliva, drink and eat; hydration, weight change and breathing. Clarify whether the problem is pain, food sticking, choking or aspiration. |
| Voice change, cough or noisy breathing | What changed in the voice and when? Persistent or intermittent? Recent infection, voice strain, intubation, head/neck/chest surgery, tobacco exposure or professional voice use? Any cough, blood, pain on speaking, breathlessness or stridor? | Communication, teaching or singing, sleep, exercise and airway safety. Ask about progression and associated neck lump or swallowing difficulty. |
| Oral lesion or neck lump | Where is it, when was it first noticed, and is it growing, painful, ulcerated or changing? For a lump: exact site, side, mobility as noticed by the patient, tenderness, fluctuation and related infection or dental symptoms. Tobacco, alcohol and previous cancer history may be relevant. | Eating, speech, swallowing, breathing, weight, fever, night sweats or fatigue. A persistent unexplained neck mass or oral lesion requires appropriate clinical assessment. |
These prompts help build a focused history; they are not a diagnostic checklist. Ask follow-up questions based on the patient’s answers, age, context and examination findings.
Associated symptoms and impact on daily life
ENT conditions can affect several connected functions. Ask about hearing, tinnitus, balance, smell and taste, nasal breathing, sleep, voice, speech, chewing, swallowing and pain. Also ask about fever, headache, facial symptoms, facial weakness, weight change, appetite, fatigue and general wellbeing when relevant. In children, ask about speech and language milestones, school performance, recurrent infections, feeding, breathing during sleep and caregiver concerns. In adults, ask how symptoms affect work, relationships and independence.
Clarify what matters most to the patient. Two people with similar symptoms may experience very different effects on communication, safety, sleep or employment. Their priorities help guide the next steps and shared decisions.
Relevant background history
Past medical and ENT history
- Previous ear, nose, throat, sinus, oral or neck problems and how they were managed.
- Previous infections, allergy, asthma, hearing difficulty, balance disorders, trauma or foreign bodies.
- Operations, procedures, intubation, radiotherapy or cancer treatment involving the head, neck or chest.
- Relevant general illness, immune suppression, diabetes, bleeding disorders or neurological conditions.
Medicines and allergies
- Record prescribed, over-the-counter and traditional or herbal medicines when relevant; note dose and recent changes if known.
- Ask about ear or nasal drops, antibiotics, pain medicines, anticoagulants and medicines with possible effects on hearing or balance.
- Clarify the substance and reaction for every reported allergy. Do not record “allergy” without checking what happened.
Family and developmental history
- Family history of hearing loss, congenital ear conditions, allergy, recurrent infections or relevant head-and-neck disease.
- For children, ask about pregnancy and birth only when relevant, hearing screening, speech development, school progress and caregiver observations.
- Ask what support the patient already receives, including hearing aids, speech therapy or specialist follow-up.
Personal, social and exposure history
- Tobacco smoking or chewing, alcohol use and other exposures; ask sensitively and without judgement.
- Work or hobbies involving loud noise, dust, smoke, chemicals, pressure changes or frequent water exposure.
- Use of earphones or hearing protection, recent travel or diving when relevant, living situation and access to follow-up.
- For voice symptoms, ask about teaching, singing, call-centre work or other high-demand voice use.
Red flags: recognise urgency and act
- Stridor, severe or rapidly worsening breathlessness, inability to handle secretions, rapidly enlarging throat or neck swelling, or suspected upper-airway obstruction.
- Severe uncontrolled epistaxis, significant blood loss, collapse or signs of circulatory compromise.
- Severe infection with toxic appearance, neck stiffness, confusion, rapidly spreading swelling, trismus or difficulty swallowing saliva.
- Acute facial weakness with ear or head-and-neck symptoms, new focal neurological signs, or dizziness with serious neurological features.
Arrange urgent emergency assessment through local services. Follow facility protocols and stabilise the patient within your competence while help is arranged.
- Sudden hearing loss: NICE guidance for adults advises immediate referral so specialist assessment occurs within 24 hours when hearing loss developed suddenly over 3 days or less within the past 30 days. Use the local emergency or ENT pathway; do not wait for a routine appointment.
- Persistent unexplained hoarseness or neck lump: NICE suspected-cancer guidance uses these as referral triggers in defined adult groups in UK primary care. Thresholds and referral routes differ by country; persistent or progressive symptoms need assessment using local guidance.
- Persistent unilateral nasal obstruction or blood-stained discharge, a non-healing oral lesion, unexplained weight loss, progressive swallowing difficulty or a growing neck lump should not be dismissed as routine without appropriate assessment.
- Document the red flag, its timing, the action taken, whom you contacted and the agreed follow-up. Safety-net clearly if assessment is not immediate.
The time limits above describe cited NICE guidance, not a replacement for Uganda’s Ministry of Health, district, facility or specialist referral pathways. Use the current local pathway when caring for a patient.
Review of systems: keep it relevant
A brief review can uncover symptoms the patient did not initially connect with the main complaint. Tailor it to the presentation:
- Ear and balance: hearing change, tinnitus, ear pain or discharge, vertigo, imbalance, falls and facial weakness.
- Nose and sinuses: obstruction, discharge, sneezing or itching, nosebleeds, smell change, facial pain or pressure.
- Mouth, throat and voice: ulcers or lumps, dental pain, sore throat, swallowing difficulty, voice change, cough, choking, breathing difficulty or blood.
- General and neurological: fever, weight change, appetite, fatigue, headache, vision change, weakness, numbness or other neurological symptoms when indicated.
A review of systems should clarify the case, not become an unfocused checklist. A positive answer needs follow-up; a negative answer is worth recording when it changes the differential or urgency.
Summarising and presenting the case
Finish by giving a concise, ordered summary that another clinician can understand quickly. Include who the patient is, the principal symptom and duration, the time course and side, key positive and negative features, relevant risks and background, functional impact, red flags and the action required. Avoid presenting a diagnosis as certain before examination and investigations support it.
This is a fictional teaching example. It demonstrates how to summarise symptoms and urgency; it does not diagnose the cause.
ENT history documentation template
| Heading | What to record |
|---|---|
| Patient and source | Age, relevant context, historian, relationship if a caregiver, interpreter or communication support, and reliability if needed. |
| Presenting complaint(s) | Patient’s main concern(s), duration and side; place multiple complaints in chronological order. |
| History of presenting illness | Onset, duration, course, laterality, character, severity, triggers, relieving factors, associated symptoms, previous episodes, treatment and response. |
| Function and red flags | Effect on hearing, balance, sleep, voice, eating, swallowing, breathing, school or work; urgent features and action taken. |
| Relevant background | Past medical/ENT history, operations, medicines, allergies and reactions, family history, social history and exposures. |
| Review and summary | Relevant positives and negatives, concise problem representation, differential considerations, plan, referral or safety-netting. |
Practice cases and self-check
Case 1: sudden hearing change
An adult says that hearing in one ear became markedly worse this morning. There is new tinnitus but no obvious pain. Ask when the change began, whether it was truly sudden, whether it is worsening, and about dizziness, neurological symptoms, recent infection, trauma, noise exposure and medicines. Key point: sudden hearing loss is time-sensitive and needs immediate assessment through the local pathway; history alone cannot determine whether it is conductive or sensorineural.
Case 2: persistent voice change
An adult reports a hoarse voice that has not settled and has noticed a neck lump. Ask duration, progression, pain, swallowing or breathing symptoms, weight change, tobacco and alcohol exposure, previous head-and-neck treatment and voice demands. Key point: a persistent unexplained voice change with a neck mass needs timely clinical assessment, even when the patient feels otherwise well.
Case 3: recurrent nosebleeds
A student reports repeated nosebleeds. Establish side, duration, frequency, amount, triggers, injury, medicines affecting bleeding, bruising elsewhere and symptoms of anaemia or collapse. Ask about nasal obstruction, discharge, allergy and any foreign-body possibility in a child. Key point: ongoing heavy bleeding or instability takes priority over a full history.
Check your understanding
- Why should the patient describe dizziness in their own words before you label it vertigo?
- Which details help distinguish sudden from slowly progressive hearing difficulty?
- Name four areas of function that ENT symptoms may affect.
- What should you do if the patient has stridor or cannot handle secretions?
- Why should referral thresholds from a guideline in another country be checked against local pathways?
Suggested answers: (1) “Dizziness” may mean spinning, faintness or imbalance and the distinction guides further assessment. (2) Onset, duration, laterality, progression, associated tinnitus/vertigo, exposures and relevant medicines. (3) Hearing/communication, balance, sleep, smell/taste, voice, eating/swallowing, breathing, school/work and social participation. (4) Treat as an airway emergency and arrange immediate local emergency help rather than continuing a routine interview. (5) Referral systems, thresholds and available services differ, so local guidance determines the appropriate action.
Common pitfalls to avoid
- Asking a long checklist before allowing the patient to explain the problem.
- Recording “dizziness,” “hearing loss” or “discharge” without clarifying what the patient means, when it began and which side is affected.
- Forgetting voice, swallowing, airway, facial nerve, balance or functional-impact questions when relevant.
- Assuming a symptom is harmless because it is painless or because a patient is young; consider the full history and examination.
- Missing medication, tobacco, noise, occupational or trauma exposures.
- Using a red-flag threshold from another country as if it were automatically the local Ugandan referral rule.
- Recording an unverified diagnosis instead of separating the patient’s report, observed findings, working impression and plan.
- Completing a routine history while an unstable patient needs immediate assessment.
Quick revision summary
- Start with the patient’s own story; then clarify chronology, side, character, course and associated symptoms.
- Ask system-specific questions across the ear, nose, mouth, throat, voice, balance and neck.
- Connect symptoms to function: communication, sleep, school/work, eating, swallowing, breathing and safety.
- Include relevant medical, medication, allergy, family, social and exposure history.
- Screen for emergency and urgent features as you go; document the response and handover.
- Summarise clearly and remember: history guides examination and investigation, but does not replace them.
Supplementary slides and further study
- SlideShare: ENT History Taking — a short introductory slide set on the structure of the history and the relationship between history, examination and investigations.
- SlideShare: The ENT History and Examination — additional revision slides. Use these as supplementary learning material, not as a substitute for current clinical guidance.
- Class notes: Coming soon.
Key references
- University of Iowa, Otolaryngology Medical Student Clerkship Objectives — focused ENT history, related systemic complaints, communication and referral learning objectives.
- NICE NG98: Hearing loss in adults — assessment and management — includes urgent referral guidance for recent sudden hearing loss in adults.
- NICE NG12: Suspected cancer — recognition and referral — head-and-neck symptom referral recommendations in the UK context.
- American Academy of Otolaryngology–Head and Neck Surgery: Hoarseness (Dysphonia) guidance summary — factors that can warrant earlier laryngeal assessment.
Related learning
Continue through the Clinical Medicine Year 2 Semester 1 and 2 curriculum. For related oral-health revision, see Prevention of Dental Diseases and Conditions.
Educational content for students and health workers. It is not a substitute for individual assessment, current clinical guidance, supervised practice or emergency care.
