NASOPHARYNGOSCOPY NOTE

NAME:

DATE:

DOB:

Indications:  Post-op monitoring

Diagnostic Codes:

Nasopharyngoscopy 92511

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Procedure:

A verbal informed consent was obtained and patient was placed in the upright position and spray twice in bilateral nares with 50% lidocaine and 50% Afrin solution. After waiting 5 minutes for the nasal solution to take full effect the nasopharyngoscope placed in the patients (Right) nare.

-Nasal mucous membranes were pink and moist

-Turbinates WNL

-No evidence of mass, ulceration, lesion, or obstruction.

-Eustachian tubes are patent and without obstruction bilaterally with no evidence of erythema, mass, ulceration, lesion, or obstruction

Scope was further advanced to the level of the oropharynx where the base of the tongue, vallecular, and epiglottis were visualized. Scope further advanced to the level of the hypopharynx.

-Vocal cords were visualized no lesions, edema, or erythema was noted

-Vocal fold demonstrate appropriate vibration with phonation

- Laryngeal surface of the epiglottis WNL

The scope was removed without difficulty. The patient tolerated with procedure well and remained in stable condition.

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Findings:

All findings during procedure were within normal limits

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Plan:

We will continue to do surveillance as directed by the NCCN and patient is instructed to call the office if any problems arise.

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