Clinical Notes

Biopsy Note



Patient was pre-screened per OS protocol prior to appointment.

Patient was additionally screening via phone when they arrived outside the practice and temperature was checked. 

COVID-19 Consent was completed in addition all OS paperwork . Patient signature was verified.

Room was disinfected using Super Sani-Cloth Germicidal Disposable Wipe (EPA Reg # 9480-4 ) techniques per manufactures protocols, followed by Clorox® Clean-Up® Cleaner + Bleach (EPA Reg. No. 5813-21) Spray and room dry. Room was verified by the other assistant for completion via COVID-19 Room disinfection checklist.

Patient also rinsed with 1.5% hydrogen peroxide for 30 second 

Progress NOTE


Patient seen at the request of the office general dentist for evaluation of xxxxxxx

Additionally reviewed r/b/c or surgery.

Past Medical History
Refer to patient history form

Past Surgical History
Refer to patient history form

Refer to patient history form

Refer to patient history form

Social History
Smoking – Refer to patient history form
Alcohol - Refer to patient history form
Drugs - Refer to patient history form

Extraoral, Head and Neck exam: 

Constitutional: general appearance of patient  
No extraoral swelling or erythema 
Parotid and submandibular glands soft, nonpainful to palpation bilaterally 
No lesion noted on facial skin
Facial palpitation exam reviews no swelling or no lymphadenopathy 
CN V1, V2, V3, CN VII intact bilaterally 
No neck masses noted
Thyroid midline with no evidence of any swelling
Musculoskeletal: TMJ joint seems to be normal. No poping upon opening
Maximum mouth opening within normal range

Intraoral Soft Tissues: 

Clear saliva extruded from bilateral Wharton’s and Stenson’s ducts 
Tongue soft and non-tender with no apparent lesions 
Buccal mucosa without lesions bilaterally 
Hard palate, soft palate, and pharynx are within normal limits no pathology visualized 
Floor of mouth without an evidence of pathology


Refer to dental chart for detail dental caries evaluation

Radiographic examination: 
Panorex reviewed demonstrates
No bony pathology. 

Biopsy #xxxxxxx

Discussed risk, benefits, complication of surgery including but not limited to bleeding swelling, infection, pain, retained root tip, numbness of lower lip, chin, tongue. Patient understood risks informed, verbalized understanding and consented accordingly.

Local Anesthesia
___ 2% lido w/ 1:100,000 epi Carpules (1.7 cc)
___ 4% sepocaine Carpules (1.7 cc)
___ 3% Carbocaine w/o epi Carpules (1.7 cc)

Procedure Performed
SURGEON 1:  Joseph Krajekian, D.M.D., M.D.
DENTAL ASSISTANT : Shawna / Melinda

    Biopsy of xxxxxxxx

After proper time for local anesthesia to work.
Mouth prop utilized, throat pack used followed by sweetheart.

Elliptical incision made with 0.5cm margin

Lesion was excised without any complication

Hemostasis achieved.

Site was closed with 3.0 gut suture



Pen VK 500mg    PO q6 hrs Disp 7 days                     refill 0
Norco 5/325        1 tabs PO q6 hrs prn Disp 5 days    refill 0
Peridex                Provided from the office                  refill 0
Mortin 800mg      1 tablet every 8 hrs prn x 28 pills    refill 0


3-4 weeks. Patient was provided post-op instruction/medication sheets in writing and they were also review with patient escort. Pt was also provided with my 24 hour direct contact number and was also instructed to contact the office with any questions

Biopsy Submitted to

       __  Strata DX    _X_  Tufts University


Post-op Instructions

       _X_  Verbal    _X_ Written


Followup in _3-4__ weeks

DICTATED BY :                    
Dr. Joseph Krajekian DMD, MD