Dr. Joseph Krajekian DMD, MD, FAAOMS, DABOMS
Board Certified Oral and Maxillofacial Surgeon
Clinical Notes
Biopsy Note
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Progress NOTE
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Patient seen at the request of the office general dentist for evaluation of xxxxxxx
Additionally reviewed r/b/c or surgery.
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Past Medical History
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Refer to patient history form
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Past Surgical History
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Refer to patient history form
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Medications
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Refer to patient history form
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Allergies
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Refer to patient history form
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Social History
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Smoking – Refer to patient history form
Alcohol - Refer to patient history form
Drugs - Refer to patient history form
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CLINICAL EXAMINATION:
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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
Dentition:
Refer to dental chart for detail dental caries evaluation
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Radiographic examination:
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Panorex reviewed demonstrates
No bony pathology.
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ASSESSMENT / PLAN / RECOMMENDATION
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Biopsy #xxxxxxx
CONSENT
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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.
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Local Anesthesia
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___ 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)
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Procedure Performed
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SURGEON 1: Joseph Krajekian, D.M.D., M.D.
DENTAL ASSISTANT : Shawna / Rae
OPERATION/PROCEDURE :
Biopsy of xxxxxxxx
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After proper time for local anesthesia to work.
Mouth prop utilized, throat pack used followed by sweetheart.
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Elliptical incision made with 0.5cm margin
Lesion was excised without any complication
Hemostasis achieved.
Site was closed with 3.0 gut suture
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ESTIMATED BLOOD LOSS: minimal
DISPOSITION : Home
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PRISCRIPTION DISPENSED:
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Pen VK 500mg PO q6 hrs Disp 7 days refill 0
Tylenol #3 1 tabs PO q6 hrs prn Disp 5 days refill 0
Peridex Provided from the office refill 0
Motrin 800mg 1 tablet every 8 hrs prn x 28 pills refill 0
FOLLOWUP :
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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
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Biopsy Submitted to
__ Strata DX _X_ Tufts University
Post-op Instructions
_X_ Verbal _X_ Written
Followup in _3-4__ weeks
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DICTATED BY :
Dr. Joseph Krajekian DMD, MD