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 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