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| Physical Exam | 03/12/XX |
ENT: Oropharynx showed presence of granular lesion involving lateral aspect of uvula creeping towards edge of soft palate and onto posterior pillar on the left side. No lymphadenopathy. |
| X-Rays & Scans | 03/12/XX |
CXR: Question of nodule in right lower lobe. CT Neck: questionable minimal soft tissue thickening without gross evidence of enhancement within the left lateral aspect of soft palate and uvula. No evidence of neck lymphadenopathy. |
| Scopes | 03/12/XX | Direct laryngoscopy with biopsy of soft palate and uvula. Findings: granular lesion of soft palate appears to be involving uvula. |
| Laboratory |
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None |
| Operative Findings |
03/12/XX |
Excision of palatal carcinoma, tonsillectomy, palatal pharyngoplasty. Findings: Palatal carcinoma involving uvula extending along left edge of soft palate onto anterior and posterior pillar with no direct infiltration of tonsil. |
| Pathological Reports | 03/12/XX |
Micro: Infiltrating moderately to poorly differentiated focally keratinizing squamous cell carcinoma arising from epithelium of uvula. Deep margins free. Epithelial margins negative. Tumor size 1.0 cm. |
| Treatment | 03/22/XX | Surgery: Excision of palatal carcinoma, tonsillectomy, palatal pharyngoplasty. |
