DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Nasal tissue necrosis and infection.
POSTOPERATIVE DIAGNOSIS: Nasal tissue necrosis and infection.
OPERATION PERFORMED: Right nasal cavity biopsy.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
COMPLICATIONS: None immediate.
CONDITION: Stable.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old male with a several-month long-standing history of right greater than left nasal cavity and tip infection and necrosis, who has been seen and treated in the past with antibiotics. He presents today for definite biopsy specimens to address further infectious versus cancerous etiology.
DESCRIPTION OF OPERATION: The patient was brought into the operating room, and an appropriate plane of anesthesia was obtained via general endotracheal intubation. The patient was prepped and draped in the standard fashion. Afrin-soaked pledgets were placed in the bilateral nasal cavities.
Biopsy forceps were then used to collect diffuse biopsy specimens from the right nasal cavity, and these were sent for multiple microbiology samples, flow cytometry, frozen and permanent pathology. Nasal endoscopy was then performed using a 0-degree Hopkins rod. The left nasal cavity within the vestibule did not show any evidence of disease, and the nasal cavity was clear to the nasopharynx. The right nasal cavity has significant necrosis, was inflamed, friable mucosa in the anterior one-third to one-half nasal cavity. At the distal aspect of this necrosis, the nasal cavity was patent and without evidence of disease. The nasopharynx was also clear at this point.
Once appropriate samples were deemed sufficient by pathology, the procedure was completed. There were no immediate complications. The patient was transported to the PACU in stable condition.
PLAN:
1. The patient is to follow up with Dermatology within the week.
2. Hematology-Oncology was informed of the patient’s status, and they will arrange for followup visit in the clinic, potentially pending permanent tissue samples from the pathology section.
3. At this point, several microbiology and pathology specimens will be pending to assess for lymphoma versus some other infectious etiology.
