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CASE 2: ENT. General Data. J.Y. 13 y/o Female Single Filipino Roman Catholic from Butuan City, Agusan del Norte. Chief Complaint. Enlarged tongue. Px born to a 23 y/o primigravid via NSD at a tertiary hospital

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CASE 2: ENT

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Case 2 ent

CASE 2: ENT


General data

General Data

  • J.Y.

  • 13 y/o Female

  • Single

  • Filipino

  • Roman Catholic

  • from Butuan City, Agusan del Norte


Chief complaint

Chief Complaint

  • Enlarged tongue


History of present illness

  • Px born to a 23 y/o primigravid via NSD at a tertiary hospital

  • (+) prenatal check-up, denies any exposure to radiation/ intake of teratogenic drugs

  • Admitted at a local hospital due to swelling and bleeding of tongue.

  • Given unrecalled antibiotics.

  • Advised to transfer to another hospital but px did not comply due to lack of funds.

  • Mother noted spontaneous resolution of tongue swelling.

  • Noted by the attending physician to have enlarged tongue.

  • No medications given, no further consultation advised.

  • (-) Difficulty feeding, dyspnea, snoring

History of Present Illness

  • OB Hx

  • 12 years PTA

  • 13 years PTA


History of present illness1

  • Persistence of symptoms led to consult with a private ENT in Davao

  • (+) progressive enlargement of the tongue

  • (+) episodes of bleeding and swelling of the tongue 3-4x/ year.

  • Px would seek consult with MD and unrecalled antibiotics were given.

History of Present Illness

  • 3 years PTA

  • Interval history (1997-2007)


History of present illness2

  • (+) persistent bleeding and swelling of tongue

  • (+) pain on the anterior 1/3 of the tongue.

  • Can only tolerate minced and soft foods.

  • Noted to be pale and weak by the mother.

History of Present Illness

  • 2 months PTA

ADMISSION


Review of systems

Review of Systems

  • (-) weight loss

  • (-) skin rashes, changes in pigmentation

  • (-)blurring of vision, headache

  • (-) decreased hearing sensation, tinnitus, dizziness

  • (-)cough and colds, chest pains, palpitations

  • (-)abdominal pain, changes in bowel/bladder function

  • (-)edema, joint pains, muscle pains


Past medical history

Past Medical History

  • (-) allergies

  • (-)PTB

  • (-) hepatitis

  • (-) asthma

  • (-) previous surgeries and blood transfusions


Menstrual and obstetric history

Menstrual and Obstetric History

  • Menarche – 12 y/o

  • Irregular period

  • Duration: 4-5 days

  • Amount: 5 pads/day

  • Symptoms – dysmenorrhea


Family history

Family History

  • (-) HPN

  • (-) DM

  • (-) Asthma

  • (-) PTB

  • (-) Ca

  • (-) Down’s Syndrome


Personal and social history

Personal and Social History

  • H – has good relations with other family members and persons at home

  • E – 1st year high school, average student

  • A – enjoys watching TV and DVD

  • D – no hx of illicit drug use, smoking, intake of alcoholic beverages

  • S – has few friends, rarely goes out

  • S – no sexual activity


Physical examination

Physical Examination

  • Weight – 39 kg

  • Height – 144 cm

  • BMI – 20

  • BP – 100/70

  • PR – 84 bpm

  • RR – 22c pm

  • T – 36.7


Physical examination1

Physical Examination

  • Height for age – normal; Z score below -1

  • BMI for age – normal; Z score 0 (median)

  • Conscious, coherent, ambulatory, not in cardiorespiratory distress

  • Warm moist skin, no rashes

  • Anicteric sclera, pink palpebral conjunctivae


Physical examination2

Physical Examination

  • Symmetric chest expansion, clear breath sounds

  • Adynamicprecordium, AB at 5th LICS MCL, no murmurs, no thrills

  • Flat abdomen, NABS, soft, nontender

  • Full and equal pulses, no swelling, no edema

  • SMR = 3


Ent examination

ENT Examination

  • Anterior rhinoscopy: midline septum, turbinates not congested, no nasal polyps

  • Oral cavity: (+) enlarged reddened tongue; (+) multifocal, pebbly, vesicle like lesions on the tip, dorsal and lateral surfaces of the anterior 1/3 of the tongue; (+) blood clots on dorsal and ventral surface of anterior 1/3 of tongue; moist buccal mucosa


Ent examination1

ENT Examination

  • Pharynx – nonhyperemic posterior pharyngeal wall, tonsils not enlarged

  • Otology: AD – no tragal tenderness, nonhyperemic EAC, intact TM; AS – no tragal tenderness, nonhyperemic EAC, intact TM

  • Face and neck: no facial asymmetry, neck masses, thyromegaly, palplable lymph nodes


Neurologic examination

Neurologic Examination

  • conscious, coherent, oriented to 3 spheres;

  • pupil 2-3 mm ERTL, EOMs full and equal

  • can clench teeth, can raise eyebrows, can close eyes tightly, can smile, can frown

  • no hearing loss, limited side to side head turning, tongue midline on protrusion

  • can do FTNT and APST

  • MMT 5/5 on all extremities

  • DTR ++ on all extremeties

  • no sensory deficits


Salient features

Salient Features


What is your impression of the case

MacroglossiaSecondary to

Lymphangiomaof the Tongue

Guide Question 1

What is your impression of the case?


Put your discussion

PUT YOUR DISCUSSION


What laboratory exams would you recommend

Biopsy of the Tongue

Thyroid assays

Imaging Studies: CT Scan, MRI of the Head & Neck

Guide Question 2

What laboratory exams would you recommend?


Case 2 ent

  • Biopsy of the tongue

  • Thyroid function test – to rule out hypothyroidism

  • Imaging Studies – to determine extent of lesion and pre-operative planning

    • CT Scan

    • MRI – test of choice


Histologic findings in biopsy of the tongue

Histologic Findings in Biopsy of the Tongue


What will be suggested treatment

Tongue Resection and Reconstruction

Guide Question 3

What will be suggested treatment?


Put your discussion1

PUT YOUR DISCUSSION

  • No proven medical care for lymphangiomasexists. This condition is not responsive to radiation therapy or steroids.


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