ADMISSION CONFERENCE Patricia Amolenda

General Data A.B. 18 month old/female Roman Catholic DOA: March 27, 2011

Chief Complaint Tongue-tied

History of Present Illness Born to a 35 year-old, G3P3 (3003) During pregnancy, she had no known medical illness and had regular prenatal check ups at UST OPD-OB. No exposure to radiation, viral exanthems and teratogenic drugs. Non smoker, non alcohol beverage drinker and no illicit drug use

History of Present Illness Born via NSD, cephalic, term at USTH-CD, with a birth weight of 3.2 kg No complications after birth Newborn and Hearing screening were negative.

History of Present Illness noted by her parents to have be less talkative compared to other children. (only able to say “mama” and ”papa”) consult at a private physician OAE: passed, bilateral Noted short lingual frenulum Was referred to UST OPD ENT UST OPD, ENT: Advised surgery 2 months PTA ADMISSION 3 weeks PTA

Review of Systems (-) fever, (-) weight loss, (-) anorexia (-) rash, (-) pigmentation, (-) hair loss, (-) pruritus (-)cyanosis, (-)fainting spells, (-)easy fatigability, (-) chest pain (-)difficulty of breathing, (-)cough (-)nausea, (-)vomiting, (-)abdominal pain, (-)jaundice, (-)food intolerance, (-)diarrhea, (-)constipation (-)changes in urine color, (-)dysuria, (-)frequency (-)palpitations, (-)heat/cold intolerance, (-) polyuria, (-) polydipsia, (-) polyphagia (-)tremors, (-)convulsions (-) bone/joint pain, (-)swelling, (-)limitation of motion, (-)stiffness, (-)limping (-) pallor, (-)bleeding manifestations, (-)easy bruisability

Feeding History breastfed up to 3months of age, 3 oz, twice a day started on milk formula NANHW at 1 month old, and was shifted to Promil kid at 6 months old. currently, consumes 5 bottles of milk per day, 200mL each, with a dilution of 1:2 started on complementary feeding at 4-6 months, beginning with cereals, then mashed fruits and vegetables

Developmental History Walks alone; Runs well Waves bye bye Says “mama” and “papa” only Throws objects in and out of container Feeds self with spoon Scribbles well Undresses self without help

Past Illnesses No previous surgery or hospitalization Bronchial Asthma, last attack 1 y/o, unrecalled inhaler used PRN No known allergies

Immunization History BCG 1, HepB 1 DPT 123, OPV 123 Measles vaccine

Family History HPN: mother side, father side Asthma: mother Ankyloglossia: brothers No TB, cancer, heart disease, stroke

Physical Examination on Admission General:Alert, awake, ambulatory, not in cardiorespiratory distress, well-hydrated, well- nourished Vital signs: HR: 102 bpm, regular, RR: 25cpm, regular, T 37 o C Weight: 10kg, Height: 80cm, BMI Skin: Warm and moist skin, no active dermatoses, no jaundice, good skin turgor Head: Normocephalic, black, thin hair, no hair loss, no lice and nits

Physical Examination on Admission Eyes: Pink palpebral conjunctiva, anicteric sclera, pupils 2-3mm ERTL Ears: no tragal tenderness, non hyperemic EAC, (+) retained cerumen, AU, intact TM, AU Nose: No nasal septum deviation, turbinates not congested, no discharge Throat: moist buccal mucosa,no dental caries, nonhyperemic PPW, tonsils not enlarged, short, lingual frenulum attached to the tip of the tongue

Physical Examination on Admission Neck: Supple neck, no palpable cervical lymph nodes, no thyroid enlargement, no tenderness Chest: Symmetrical chest expansion, resonant, clear and equal breath sounds Heart: Adynamic precordium, apex beat at 4 th LICS MCL, no thrills/ heaves, S1>S2 at apex, S2>S1 at base, no murmurs Abdomen: Flat abdomen, inverted umbilicus, NABS, tympanitic, no organomegaly, no palpable mass, no abdominal tenderness, Extremites: Full and equal pulses on all extremities, no edema, no cyanosis

Neurological Exam Alert, awake, irritable, able to follow commands (+) direct pupillary light reflex, able to hear spoken words No abnormal/ involuntary movements of the extremities No sensory deficit No involuntary movements, no spasticity, no atrophy

Salient Features 18 month old, female Says “mama” and “papa” only Family history of ankyloglossia Short, lingual frenulum attached to the tip of the tongue

Assessment Ankyloglossia

Plans CBC, Clotting Time, Bleeding Time Chest XRray Diet for Age For release of tongue tie

Ankyloglossia congenital anomaly in which a short, lingual frenulum or a highly attached genioglossus muscle restricts tongue movement the reported prevalence varies from <1 percent to 10.7 percent

Clinical Features Abnormally short frenulum, inserting at or near the tip of the tongue Difficulty lifting the tongue to the upper dental alveolus Inability to protrude the tongue more than 1 to 2 mm past the lower central incisors Impaired side-to-side movement of the tongue Notched or heart shape of the tongue when it is protruded

Associated Problems Breastfeeding problems Articulation problems Mechanical problems

Breastfeeding Problems breastfeeding problems (eg, poor latch, maternal nipple pain) are reported 22% more frequent among infants with ankyloglossia than without ankyloglossia

Articulation Problems may cause articulation problems in some children, but does not prevent vocalization or delay the onset of speech frenula that extend to the tip of the tongue and prevent the tongue from reaching the upper dental alveolus Speech sounds that may be affected include "t," "d," "z," "s," "th," "n," "l"

Mechanical Problems Difficulty with oral hygiene (ie, licking the lips or sweeping food debris from the teeth) that may result in periodontal Local discomfort Diastasis between the lower central incisors Difficulty licking an ice-cream cone, playing a wind instrument, or kissing

MANAGEMENT Surgery is the definitive treatment Indications – Breastfeeding difficulty, articulation problems, psychologic problems, and periodontal disease The optimal timing of surgery is controversial