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1. GRAND ROUNDS Department of Health SOUTHERN PHILIPPINES MEDICAL CENTER Department of Otolaryngology-Head & Neck Surgery Presenter: Dr. Leorag / Dr. Buenaventura Surgeon: Dr. Opay 28 June 2024

2. P.C. 54/M Married Filipino Roman Catholic General Santos City HISTORY PHYSICAL EXAM GENERAL DATA CHIEF COMPLAINT DIAGNOSTICS SALIENT FEATURES DIFFERENTIAL DIAGNOSIS WORKING IMPRESSION PLAN

3. Maxillary Mass, Right HISTORY PHYSICAL EXAM GENERAL DATA CHIEF COMPLAINT DIAGNOSTICS SALIENT FEATURES DIFFERENTIAL DIAGNOSIS WORKING IMPRESSION PLAN

4. HISTORY PHYSICAL EXAM GENERAL DATA CHIEF COMPLAINT DIAGNOSTICS SALIENT FEATURES DIFFERENTIAL DIAGNOSIS WORKING IMPRESSION PLAN HISTORY OF PRESENT ILLNESS Past Medical History Family History Personal/Social History Review of Systems 10 years prior to admission Onset of right maxillary mass approximately 1x1 cm firm, nontender, nonfluctuant No associated symptoms No consult done, no meds taken

5. HISTORY PHYSICAL EXAM GENERAL DATA CHIEF COMPLAINT DIAGNOSTICS SALIENT FEATURES DIFFERENTIAL DIAGNOSIS WORKING IMPRESSION PLAN History of Present Illness PAST MEDICAL HISTORY Family History Personal/Social History Review of Systems PAST MEDICAL HISTORY Known hypertensive Losartan Amlodipine No Diabetes mellitus type 2 No Bronchial asthma No food and drug allergy

6. HISTORY PHYSICAL EXAM GENERAL DATA CHIEF COMPLAINT DIAGNOSTICS SALIENT FEATURES DIFFERENTIAL DIAGNOSIS WORKING IMPRESSION PLAN History of Present Illness Past Medical History FAMILY HISTORY Personal/Social History Review of Systems FAMILY HISTORY (+) Hypertension - maternal No Diabetes Mellitus No Bronchial asthma No Cancer No Pulmonary Tuberculosis

7. PERSONAL/SOCIAL HISTORY Body Guard 3 pack-year smoker Occasional alcoholic drinker Previous illicit drug (Marijuana and shabu) user for 10 years HISTORY PHYSICAL EXAM GENERAL DATA CHIEF COMPLAINT DIAGNOSTICS SALIENT FEATURES DIFFERENTIAL DIAGNOSIS WORKING IMPRESSION PLAN History of Present Illness Past Medical History Family History PERSONAL/SOCIAL Review of Systems

8. REVIEW OF SYSTEMS HISTORY PHYSICAL EXAM GENERAL DATA CHIEF COMPLAINT DIAGNOSTICS SALIENT FEATURES DIFFERENTIAL DIAGNOSIS WORKING IMPRESSION PLAN History of Present Illness Past Medical History Family History Personal/Social History REVIEW OF SYSTEMS GENERAL: (+) weight loss , fever, pallor SKIN: (-) itching, skin rashes, dryness, cyanosis HEENT: (-) watery eyes, (-) itchy nose, (-) facial pain, (+) nasal congestion RESPIRATORY: (-)dyspnea, (-)SOB CARDIOVASCULAR: (-) palpitations, cyanosis, chest pain, syncope GASTROINTESTINAL: (-) diarrhea/constipation, melena/hematochezia, abdominal pain GENITOURINARY: (-) nocturia, urgency, intermittency, flank pain, hematuria EXTREMITIES: (-) Edema

9. Anthropometrics Weight: 75 kg Height: 165 cm BMI: 27.5

10. ENT PHYSICAL EXAMINATION

11. Acquired consent from patient to show his face PATIENT’S PROFILE

12. Ears AD (-) Tragal Tenderness No Masses or Lesions on the External Ear (-) Discharges Patent EAC, Nonhyperemic, Nonswollen Intact Tympanic membrane, Nonhyperemic, Nonbulging, No Perforations AS (-) Tragal Tenderness No Masses or Lesions on the External Ear (-) Discharges Patent EAC, Nonhyperemic, Nonswollen Intact Tympanic membrane, Nonhyperemic, Nonbulging, No Perforations

13. Right Left Otoscopy

14. Anterior Rhinoscopy Right Left

15. Nasal Endoscopy Right Left

16. Oral Cavity

17. Oral Cavity/Orophraynx

18. Eye Examination Pupils Pupils round and equally reactive to light and accommodation. Motility Full range of Extra ocular muscles movement Visual acuity OD: CF OS: 20/20 Normal Intra-ocular Pressure 16/14

19. Neurologic Examination CRANIAL NERVE EXAMINATION: CN I: INTACT CN II: 2-3MM EBRTL CN III, IV, VI: INTACT EOM, NO LIMITATIONS ON MOVEMENT CN VII: HOUSE-BRACKMANN V, RIGHT CN VIII: CAN GROSSLY HEAR CN IX, X: INTACT GAG REFLEX CN XI: CAN SHRUG SHOULDER AGAINST RESISTANCE CN XII: TONGUE IN MIDLINE NO MENINGEAL SIGNS NO NUCHAL RIGIDITY

20. SALIENT FEATURES History Physical Examination

21. Right Maxillary Mass, Rule out Malignancy WORKING IMPRESSION

22. MAXILLARY SINUSES DEVELOPMENT