ENT CASE PRESENTATION

GENERAL DATA

• A.C. • 5 Years old • Female• Calinan, davao city • DOA : 11/12/2013

CHIEF COMPLAINT

LEFT , SUBMANDIBULAR MASS

History of Present Illness

2 Months PTA •Onset of left sumandibular mass, appr. Size of 4X3cm •(-) pain or discomfort •(-) consultation done, (-) meds taken

1 ½ month PTA

•Persistent mass , noted to increase in size associated with:•(+) cough, productive , yellow sputum •(+) runny nose •pain and tenderness of the left submandibular mass•(+) consult, US of neck done and CXR done( bronchopneumonia)•Given co-amoxiclav for Bronchopneumonia.

Revealed…

• Large, well defined anechoic meteor shaped lesion with low to medium level echoes approx. measured 4.5*4.5*2.2 cm in the left buccal region. Its tail is in the left sublingual space and its seen passing through the mylohyoid defect ending with its head in parapharyngeal space. This structure is abutting the carotid artery at the level of C3-C5 and just above the left thyroid lobe. The lesion is also medial to left submandibular gland. It exhibit thick vascular septation.

History of Present Illness

1 Month PTA, •Cough resolved and mass regressed in size. •Now not associated with pain or discomfort

3 days PTA, •Persistence of the mass prompted consultation and advised surgery, hence patient admitted.

Past medical history

• No Previous admission• (-) FDA

Family History

• (+) cancer – paternal side ( throat cancer ) • no other heredofamilial disease present.

PRENATAL AND MATERNAL HISTORY

• Maternal - 24 years old, married , housewife.

• Pregnancy – G2P2, uneventful pregnancies.

• Labor - spontaneous labor at term.

• Delivery – born vaginally without any complications with birth weight of 2.8kgs

• Neonatal – baby was non cyanotic, pink, with normal heart rate and respiratory rate. She had spontaneous movements and cried immediately after birth.

Nutritional history

• Breastfeeding up to 6 months.• Started with formula milk and solid food at 6

months of age.

PERSONAL AND SOCIAL HISTORY

• Studying in kindergarten 2. • Actively participates in extracurriculum

activities. • Has lots of friends and like to play with them.• no one in the family smokes or drinks alcohol.

REVIEW OF SYSTEMS• GENERAL(-)anorexic and cachexia(-) Fever (-) Weight loss recently

• SKIN(-) Rashes , Itching

• HEAD(-) Trauma

• EYES(-) Redness(-) Itching, lacrimation.

• EARS(-) Infections(-) discharges

• NOSE(-) Epistaxis, (+)Occasional Colds

• MOUTH(-) Bleeding gums(-) dysphagia(-) disturbance in eating(-)mass not noted to enlarge while eating

• NECK AND THROAT(-) Sore throat , (-) difficulty swallowing (-)tonisillitis

REVIEW OF SYSTEMS

• GASTROINTESTINAL(-) vomiting (-) food intolerance , (-)

bowel changes (-) hematemesis,

• PULMONARY SYSTEM(+)Occasional cough , (+)sputum production, (-) dyspnea

• CARDIAC(-) congenital heart disease

• GENITO-URINARY(-) urinary frequency

• NEUROLOGICAL SYSTEM (-) seizure (-) Headache • MUSCULOSKELETAL(-) Weakness(-) Joint stiffness, scoliosis, lordosis, swelling.

PHYSICAL EXAMINATION• GENERAL : awake, conscious , active , a febrile not in respiratory distress • VITAL SIGNS: HR- 98 , RR- 25 , TEMP- 36.8 C Weight: 15.5 Kg Height: 100 cm • SKIN : Warm to touch good skin turgor

HEAD

EAR

NASAL CAVITY

ORAL CAVITY

OROPHARYNX

NECK

Immunization history