GRAND ROUNDS

JI ARIANE PEARL VIDAS

NOVEMBER 22, 2018
GENERAL DATA
• Patient A.S.
• 15/F
• Single
• Oriental Mindoro
CHIEF COMPLAINT
• Mass, hard palate, left
HISTORY PRESENT ILLNESS
• 5 years PTA
• Patient noted a mass on the left hard palate.
• mass was noted to be pea sized, flat, soft to firm, nonmovable,painless
• No history of trauma, no bleeding, no discharge
• No fever, no dysphagia
• Due to persistence of the mass, patient opted to sought consult at a private
ENT Clinic wherein CT Scan of the neck was requested
• CT SCAN OF THE NECK Result:
• There is a small well-defined solid nodule (1.2x1.5x 1.05 cm (AP x T x CC)in
the left hard palate abutting the molar
• The adjacent alveolar and maxillary floor shows remodeling with sclerosis of
the border.
• Postcontrast images shows homogenous enhancement.
• Histologic examination can be done for histologic correlation.
HISTORY PRESENT ILLNESS
• Patient was advised observation. No take home medications were
prescribed.
HISTORY PRESENT ILLNESS
• Interval History
• There was noted gradual increase in size of the mass with same character,
soft to firm, nonmovable, painless with no discharge and bleeding.
• No medications were taken.
• No consult done.
HISTORY PRESENT ILLNESS
• 2 months PTA,
• Patient noted an increase in the size of the mass, reaching the size of a one
peso coin
• Patient opted consult at the same ENT clinic they’ve been to 5 years PTA
• Patient was requested with repeat CT SCAN of the paranasal sinuses
• CT SCAN OF THE PARANASAL SINUSES

• There is interval increase in the size of the well-defined soft tissue density
nodule in the left hard palate abutting the molar now measuring 2.6x 2.5 x
2.2 cm about 1.44 x 1.5 x 1.05 cm.
• There is further destruction f the adjacent alveolar and palatine process of
the maxillary bone.

• Postcontrast images show heterogenous enhancement.

• There are few subcentimeter lymph nodes in the left high jugular chain about
0.57cm, 0.82cm, 0.37 cm, 0.69cm, 0.33 cm, 0.53 cm and 0.6 cm

• Tissue correlation is recommended.

HISTORY PRESENT ILLNESS
• Patient was then referred to OMMC, hence admission.
 PAST MEDICAL HISTORY
(+) Bronchial Asthma
• Diagnosed last 2011 at a private clinic
• No maintenance medications
• Last attack: 2015
No hypertension
No Diabetes Mellitus
No PTB
No Chickenpox
(+) Measles (infancy)
No known allergy to food/ medications
No previous hospitalizations or surgical procedures done
 FAMILY HISTORY
• (+) Bronchial Asthma (brother)
• (-) Hypertension
• (-) DM
• (-) CAD, CVD
• (-) Malignancy
• (-) Thyroid, Liver disease
• (+) Kidney disease (paternal)
PERSONAL & SOCIAL HISTORY
• Currently Grade 10
• Lives with parents and siblings
• Non Smoker
• Non Alcoholic beverage drinker
REVIEW OF SYSTEMS
General:
- (-) FEVER
- (-) WEIGHT LOSS
Skin:
- (-) rashes, sores, itching, dryness

HEENT:
- (-) tinnitus (-) photophobia (-) colds (-)epistaxis (-) eye or
ear discharge
Neck:
- (-) stiffness

Respiratory:
- (-) hemoptysis

Cardiovascular:
- (-) chest pain or discomfort; (-) palpitations
Gastrointestinal:
- (-) abdominal pain (-) diarrhea (-) constipation

Urinary:
- (-) dysuria (-) frequency (-) urgency

Hematologic:
- (-) easy bruising or bleeding

Endocrine:
- (-) heat/cold intolerance; (-) excessive sweating
PHYSICAL EXAMINATION
 GENERAL SURVEY
• awake, coherent, not in distress
 VITAL SIGNS
• BP: 100/70
• HR: 92
• RR: 20
• TEMP: 36.7
• O2 SAT: 98%
OTOSCOPY

TM intact, AU
EXTERNAL EAR EXAMINATI0N

(-) tragal tenderness, AU

(-) discharge, AU
ANTERIOR RHINOSCOPY

septum at midline
(+) bulge on the nasal floor at the level of the anterior most part of the inferior turbinate
Pink turbinates
(+) Clear discharge, bilateral
POSTERIOR RHINOSCOPY

septum at midline
(-) mass
Empty nasopharynx
ORAL CAVITY EXAMINATION
(+) 3x2 cm, firm, nonmovable,
nontender violaceous mass on the
hard palate, left
with the following borders:
Anteriorly: level of the canine, left
Laterally: upper alveolar ridge
(1st, 2nd and 3rd molars)
Posteriorly: junction of the hard and
soft palate
Medially: just before the midline

(-) tonsillopharyngeal congestion, no exudates

Uvula at midline
INDIRECT LARYNGOSCOPY
PHONATION RESPIRATION

Symmetrically movable vocal cords

No pooling of saliva within the pyriform sinus
(-) mass, lesions
HEAD AND NECK EXAMINATION

No cervical lymphadenopathy
No mass
Nonpalpable thyroid
No limitation in range of motion
OTHER TESTS:
• (+) Transillumination, bilateral
- Diminished transillumination on the left vs right
TUNING FORK TEST
TEST RIGHT LEFT
WEBER TEST No lateralization
RINNE TEST AC> BC AC> BC
BING TEST Positive Positive
SCHWABACH TEST Equal Equal
 NEUROLOGIC
• CN I- able to smell
• CN II & III- PERTL (3mm->2 mm)
• CN II, IV, VI- intact EOMS
• CN V- able to clench jaw, (+) bicorneal reflex
• CN VII- no facial asymmetry,able to frown, close
eyelids, puff cheeks on both sides of face
• CN VIII- intact gross hearing,
• CN IX & X- good gag
• CN XI- equal shoulder shrug
• CN XII- tongue at midline
 MOTOR
5/5 4/5
5/5 4/5

SENSORY
100% 100%
100% 100%

DTRs
++ ++
++ ++
PRESENT WORKING IMPRESSION
MASS, HARD PALATE, LEFT
T/C MALIGNANCY