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. 
Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx

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