Common Office ProceduresCommon Office Procedures

Baby Health ServiceBaby Health ServiceLexington, KYLexington, KY

Spalding UniversitySpalding UniversityLouisville, KYLouisville, KY

Delwin B. Jacoby, DNP, APRNDelwin B. Jacoby, DNP, APRN

Delwin B. Jacoby, MSN, APRNDelwin B. Jacoby, MSN, APRNhas no financial interest or has no financial interest or affiliations with any entities affiliations with any entities

regarding this content – April regarding this content – April 17, 201317, 2013

Objectives for Common Office Procedures Objectives for Common Office Procedures

Review AHA recommendations for antibiotic prophylaxis Review AHA recommendations for antibiotic prophylaxis for common office procedures.for common office procedures.

Demonstrate removal procedures for veruccae and Demonstrate removal procedures for veruccae and acrochordons.acrochordons.

Discuss management of subungual hematomas.Discuss management of subungual hematomas.

Develop a plan for the management of ingrown toenails.Develop a plan for the management of ingrown toenails.

Demonstrate correct procedure for a digital nerve block Demonstrate correct procedure for a digital nerve block in both hands and feet.in both hands and feet.

Perform incision and drainage of an uncomplicated Perform incision and drainage of an uncomplicated abscess and paronychia.abscess and paronychia.

Demonstrate procedures to biopsy suspicious lesions– Demonstrate procedures to biopsy suspicious lesions– shave biopsy, punch biopsy, and elliptical excision.shave biopsy, punch biopsy, and elliptical excision.

Overview of Simple Office Overview of Simple Office ProceduresProcedures

Can be performed in most any officeCan be performed in most any office Requires the following:Requires the following:

good light sourcegood light source exam tableexam table mayo stand/tablemayo stand/table basic instruments and equipmentbasic instruments and equipment protective gearprotective gear anesthesiaanesthesia suture materialsuture material

Basic Instruments & Equipment Basic Instruments & Equipment

Scalpels, scissors, punchesScalpels, scissors, punchesForcepsForcepsUndermining scissorsUndermining scissorsHemostatsHemostatsNeedle holdersNeedle holdersSyringes and needlesSyringes and needlesCotton swabsCotton swabsLiquid nitrogen/cryo Liquid nitrogen/cryo Gauze padsGauze padsSuture materialSuture materialEnglish Nail Anvil *English Nail Anvil *

Universal Universal PrecautionsPrecautions

&&Sterile TechniqueSterile Technique

Antibiotic ProphylaxisAntibiotic Prophylaxis

April 2007 - New AHA guidelines for antibiotic prophylaxisApril 2007 - New AHA guidelines for antibiotic prophylaxis

– Prosthetic cardiac valve Prosthetic cardiac valve – Previous infective endocarditis Previous infective endocarditis – Congenital heart disease only in the following categories: Congenital heart disease only in the following categories:

Unrepaired cyanotic congenital heart disease, Unrepaired cyanotic congenital heart disease, including those with palliative shunts and conduitsincluding those with palliative shunts and conduitsCompletely repaired congenital heart disease with prosthetic Completely repaired congenital heart disease with prosthetic material or device, whether placed by surgery or catheter material or device, whether placed by surgery or catheter intervention, during the first six months after the procedure*intervention, during the first six months after the procedure*  Repaired congenital heart disease with residual defects at the Repaired congenital heart disease with residual defects at the site site or adjacent to the site of a prosthetic patch or prosthetic or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialization)device (which inhibit endothelialization)

– Cardiac transplantation recipients with cardiac valvular disease Cardiac transplantation recipients with cardiac valvular disease

Acrochordons (Skin Tags)Acrochordons (Skin Tags)

• Commonly found on neck, Commonly found on neck, axilla, bra-line, groinaxilla, bra-line, groin

• Topical Anesthesia +/-Topical Anesthesia +/-• EMLAEMLA• Cetacaine sprayCetacaine spray

• Grasp tag with forceps and Grasp tag with forceps and snip base with sharp scissorssnip base with sharp scissors

• Apply pressure for hemostasis Apply pressure for hemostasis and dressand dress

• Review S & S of infectionReview S & S of infection• No follow-up neededNo follow-up needed• Few complications Few complications

Acrochordons (Skin Tags)Acrochordons (Skin Tags)

CPT - 11200 - Removal any method of up to 15 tags any area

CPT – 11201 – Removal of each additional 10 lesions.

WartsWartsCommon, generally benign Common, generally benign condition of viral etiologycondition of viral etiologyChallenging!!!!Challenging!!!!Commonly spread by auto-Commonly spread by auto-inoculationinoculationCosmetically unappealingCosmetically unappealingOften resolve Often resolve spontaneouslyspontaneouslyTend to be recurrent no Tend to be recurrent no matter the treatment optionmatter the treatment optionOccur most commonly in Occur most commonly in childrenchildren

Types of Warts (Verrucae)Types of Warts (Verrucae)

Verruca vulgaris – common wartsVerruca vulgaris – common warts

Periungual warts – occur around nailsPeriungual warts – occur around nails

Verruca planus – flat wartsVerruca planus – flat warts

Verruca plantaris – plantar wartsVerruca plantaris – plantar warts

Condylomata acuminataCondylomata acuminata

WartsWartsEpidermal overgrowths caused by HPV. Spread Epidermal overgrowths caused by HPV. Spread by direct contact. by direct contact.

HPV type 1,2,4 – Assoc with Plantar Warts HPV type 1,2,4 – Assoc with Plantar Warts ((verruca plantarisverruca plantaris))

HPV type 3 &10 – assoc with Flat Warts HPV type 3 &10 – assoc with Flat Warts ((verruca planus)verruca planus)

HPV type 16,18,31 assoc with genital warts –HPV type 16,18,31 assoc with genital warts –assoc with genital cancers (assoc with genital cancers (condylomata condylomata accuminata).accuminata).

HPV 2,4,7,27,29 – Assoc with common warts HPV 2,4,7,27,29 – Assoc with common warts ((verruca vulgaris)verruca vulgaris)

VerrucaeVerrucae

Common Treatments for WartsCommon Treatments for WartsChemical DestructionChemical Destruction– Salicylic AcidSalicylic Acid– Podophyllin/PodophylloxinPodophyllin/Podophylloxin– Trichloracetic acidTrichloracetic acid– Bichloracetic acidBichloracetic acid– OthersOthers

Immune system modulator – Imiquimod Immune system modulator – Imiquimod (Aldara)(Aldara)

CryotherapyCryotherapy– Liquid nitrogenLiquid nitrogen

Duct Tape?!?!Duct Tape?!?!

CryotherapyCryotherapy

Application of extreme cold to destroy lesionsApplication of extreme cold to destroy lesions

Easy to useEasy to use

QuickQuick

Generally good results with little scarringGenerally good results with little scarring

No local anesthesia needed/pain tolerableNo local anesthesia needed/pain tolerable

Multiple lesions can be treatedMultiple lesions can be treated

Cryotherapy - DisadvantagesCryotherapy - Disadvantages

Initial cost and set-upInitial cost and set-up

Postoperative painPostoperative pain

Lesion recurrenceLesion recurrence

Hypopigmentation may occurHypopigmentation may occur

Repeat visits commonRepeat visits common

Occasional scarringOccasional scarring

Cryotherapy - Precautions Cryotherapy - Precautions

Previous Rx to cryotherapyPrevious Rx to cryotherapyDo not use on suspected cancerous lesionsDo not use on suspected cancerous lesionsCaution around nails and nailbedCaution around nails and nailbedDo not use on eyelids, elbow, digits - relative Do not use on eyelids, elbow, digits - relative contraindicationcontraindicationNose, ears, lips, ant. tibial area - cautionNose, ears, lips, ant. tibial area - cautionDark skinDark skinVascular compromiseVascular compromiseImmunocompromised patients Immunocompromised patients

Cryosurgical SystemsCryosurgical Systems

Liquid nitrogen - 196 degrees CLiquid nitrogen - 196 degrees C

Verruca-Freeze (chemical refrigerant) - 70 Verruca-Freeze (chemical refrigerant) - 70 degrees Cdegrees C

Histofreezer (chemical refrigerant) - 55 Histofreezer (chemical refrigerant) - 55 degrees C degrees C

CryosurgeryCryosurgery

Cryosurgical ProductsCryosurgical Products

CryosurgeryCryosurgeryTechniquesTechniques

CPT - 17000 – CPT - 17000 – Destruction benign or Destruction benign or premalignant lesion by any premalignant lesion by any method, first lesion.method, first lesion.

CPT – 17003 - Destruction CPT – 17003 - Destruction benign or premalignant benign or premalignant lesion by any method, 2lesion by any method, 2ndnd – 14– 14thth lesion. lesion.

Cryotherapy - VeruccaeCryotherapy - Veruccae

Nail AnatomyNail Anatomy

Subungual HematomaSubungual Hematoma

Painful accumulation of Painful accumulation of blood under the nail blood under the nail secondary to traumasecondary to traumaEvacuation relieves painEvacuation relieves pain> 50% of nail bed > 50% of nail bed involvement suggests sig. involvement suggests sig. laceration and possible laceration and possible fracture. fracture. Assess neurovascular Assess neurovascular function prior to procedurefunction prior to procedurePatient education and Patient education and expectations are very expectations are very importantimportant

Subungual Hematoma EvacuationSubungual Hematoma Evacuation

CPT – 11740 –Evacuation of subungual hematoma

Ingrown Toenail (Onychocryptosis)Ingrown Toenail (Onychocryptosis)

Common Common

Leads to pain/ Leads to pain/ disability disability

Etiology - ill-fitting Etiology - ill-fitting shoes, improper shoes, improper toenail cutting, trauma.toenail cutting, trauma.

Ingrown toenail Ingrown toenail spicule leads to spicule leads to inflammatory response inflammatory response

Stages of Ingrown ToenailsStages of Ingrown Toenails

Stage 1 - erythema, pain, Stage 1 - erythema, pain, swellingswelling

Stage II – erythema, pain, Stage II – erythema, pain, swelling, suppurationswelling, suppuration

Stage III – granulation Stage III – granulation tissue, hypertrophy along tissue, hypertrophy along with stage II with stage II characteristicscharacteristics

Ingrown Toenail (Onychocryptosis)Ingrown Toenail (Onychocryptosis)

Ingrown Toenail ManagementIngrown Toenail Management

Stage 1 – Conservative managementStage 1 – Conservative management

Stage 2 – Partial toenail removalStage 2 – Partial toenail removal

Stage 3 – Partial toenail removal; Stage 3 – Partial toenail removal; Consider referral to Podiatrist Consider referral to Podiatrist

Partial Nail RemovalPartial Nail RemovalSoak in warm H20 prior to procedureSoak in warm H20 prior to procedure

Digital nerve block bilaterally with Digital nerve block bilaterally with plainplain 2% xylocaine or bupivacaine (marcaine) 2% xylocaine or bupivacaine (marcaine) 0.25%0.25%

Prep area with betadinePrep area with betadine

Elevate the nail edge with hemostats or Elevate the nail edge with hemostats or nail elevatornail elevator

Partial nail removal 2-3 mm with nail Partial nail removal 2-3 mm with nail splitter or sharp scissorssplitter or sharp scissors

Partial Nail Removal (Cont.)Partial Nail Removal (Cont.)Remove the wedged section by rotating Remove the wedged section by rotating the separated portion toward the healthy the separated portion toward the healthy nailnailApply phenol solution (88%) to the nail Apply phenol solution (88%) to the nail matrixmatrixApply topical antibiotic and dressingApply topical antibiotic and dressingDispense wound care instructionsDispense wound care instructionsRecheck as needed, observe for signs of Recheck as needed, observe for signs of infectioninfectionPrevention instructionsPrevention instructions

Ingrown Toenail - Partial Nail Ingrown Toenail - Partial Nail RemovalRemoval

English Nail Anvil

Ingrown Toenail - Partial Nail Ingrown Toenail - Partial Nail Removal Removal

CPT – 11730 – Avulsion of nail plate, partial or complete, simple; single

Digital Nerve BlockDigital Nerve Block

Digital Digital Nerve BlockNerve Block

***No CPT exists for digital nerve block; Service included in procedure performed.

AbscessAbscess

Incision and Drainage of AbscessIncision and Drainage of AbscessAbscessAbscess – local collection of purulent materiel in – local collection of purulent materiel in a cavity surrounded by inflamed tissue.a cavity surrounded by inflamed tissue.– produces pain, pressure and tissue damage.produces pain, pressure and tissue damage.

FuruncleFuruncle (boil) – Starts in hair follicle or sweat (boil) – Starts in hair follicle or sweat glandgland

CarbuncleCarbuncle – furuncle extends to subcutaneous – furuncle extends to subcutaneous tissue tissue

Acute Acute paronychiaparonychia – abscess around nail – abscess around nail

Bacteria involved – Mostly S. aureus and other Bacteria involved – Mostly S. aureus and other gram+ organisms, MRSA common !!gram+ organisms, MRSA common !!

Skin Tension LinesSkin Tension Lines

Indications for I & D of AbscessIndications for I & D of Abscess

An abscess must be drained in order to An abscess must be drained in order to healheal

Systemic antibiotics cannot penetrate the Systemic antibiotics cannot penetrate the abscessabscess

Check to see if the lesion is “fluctuant”Check to see if the lesion is “fluctuant”

All skin abscesses, furuncle/carbuncle, All skin abscesses, furuncle/carbuncle, inflamed epithelial cysts, paronychia with inflamed epithelial cysts, paronychia with abscess must have I & D for resolutionabscess must have I & D for resolution

Contraindications/CautionContraindications/Caution

Facial abscess - CN VIIFacial abscess - CN VII

Caution in area around vital Caution in area around vital structures such as the eye and neckstructures such as the eye and neck

Caution in areas overlying nerves and Caution in areas overlying nerves and blood vesselsblood vessels

Instruments NeededInstruments Needed

Surgical BladesSurgical Blades

I & D ProcedureI & D ProcedureDetermine skin tension lines to minimize Determine skin tension lines to minimize scarringscarringPrep skin with antibacterial agentPrep skin with antibacterial agentInject local anesthesia Inject local anesthesia Make a 90 degree stab incision with #11 scalpel Make a 90 degree stab incision with #11 scalpel bladebladeApply pressure to expel purulent materialApply pressure to expel purulent materialIf no purulent material, reassess and try againIf no purulent material, reassess and try againBreak up loculations with swab, hemostat or Break up loculations with swab, hemostat or curettecurette+/- Pack with nu-gauze *+/- Pack with nu-gauze *Apply dressingApply dressing

I&DI&DProcedureProcedure

CPT – 10060 - I & D of single or simple abscess

I & D Follow-up/Patient EducationI & D Follow-up/Patient Education

Quick shower and change outer dressingQuick shower and change outer dressingExpect additional drainage Expect additional drainage Return visit 1-2 daysReturn visit 1-2 daysManagement options at revisitManagement options at revisit– Remove packing and repackRemove packing and repack– Remove packing completelyRemove packing completely– Partially remove packingPartially remove packing

Follow-up as needed for resolutionFollow-up as needed for resolutionWarm H2O soaks?Warm H2O soaks?Complete healing takes 7-21 days or longerComplete healing takes 7-21 days or longer

Fingernail/Toenail ParonychiaFingernail/Toenail Paronychia

Infection of the nail fold.Infection of the nail fold.Usually Usually S. aureus S. aureus if acute; may be Cif acute; may be Candidaandida albicansalbicans if chronic (>6 weeks). if chronic (>6 weeks). Toenail paronychia often associated with Toenail paronychia often associated with ingrown toenail and requires partial toenail ingrown toenail and requires partial toenail removal. removal. Usually no anesthetic needed. May use ethyl Usually no anesthetic needed. May use ethyl chloride as local anesthesiachloride as local anesthesiaInsert #11 blade into area of fluctuanceInsert #11 blade into area of fluctuanceApply pressure and drainApply pressure and drainWarm H20 soaks until resolvedWarm H20 soaks until resolved

Draining ParonychiaDraining Paronychia

CPT – 10060 – I & D of single or simple abscess

Punch BiopsyPunch Biopsy

Fast and easy procedure to obtain a full Fast and easy procedure to obtain a full thickness specimen for pathology.thickness specimen for pathology.Indicated for unknown and malignant Indicated for unknown and malignant lesions.lesions.Great for diagnostic purposes for flat Great for diagnostic purposes for flat lesions.lesions.Useful to remove small, flat nevi. Useful to remove small, flat nevi. Usually good cosmetic resultsUsually good cosmetic resultsUseful to diagnose inflammatory diseaseUseful to diagnose inflammatory disease

Indications for Punch BiopsyIndications for Punch Biopsy

DiagnosisDiagnosis– Inflammatory Inflammatory

skin diseaseskin disease– Skin cancerSkin cancer

RemovalRemoval– Small neviSmall nevi– Dermatofibromas - Dermatofibromas -

challenging/often challenging/often better to not removebetter to not remove

Contraindications of Punch BiopsyContraindications of Punch Biopsy

Less than optimal biopsy technique for Less than optimal biopsy technique for SCC and BCCSCC and BCCMust Know Anatomy!!!!!!!!!!!!!!Must Know Anatomy!!!!!!!!!!!!!!– Facial nerveFacial nerve– Trigeminal nerveTrigeminal nerve– EyelidEyelid– DigitsDigits– Areas with little soft tissue – tibia, digits, ulna, Areas with little soft tissue – tibia, digits, ulna,

etcetc

Equipment for Punch BiopsyEquipment for Punch Biopsy

Punch – 2-8mm. Choose the punch that can Punch – 2-8mm. Choose the punch that can completely excise the lesion completely excise the lesion – < 3mm may not need sutures< 3mm may not need sutures– > 6mm , best to use an elliptical excision.> 6mm , best to use an elliptical excision.

Fine, sharp-sharp scissorsFine, sharp-sharp scissorsForcepsForcepsNeedle holderNeedle holderSuture materialSuture materialLocal anesthesiaLocal anesthesia

Punch Biopsy ProcedurePunch Biopsy ProcedureSterile TechniqueSterile TechniqueChoose a punch to remove entire lesionChoose a punch to remove entire lesionLocal anesthesia 1% lidocaineLocal anesthesia 1% lidocaineApply tension perpendicular to Kraissel’s lines Apply tension perpendicular to Kraissel’s lines with hand not performing the punch.with hand not performing the punch.Apply punch completely over the lesion, apply Apply punch completely over the lesion, apply pressure, and rotate through the dermis – pressure, and rotate through the dermis – expose the subq. Adipose tissue.expose the subq. Adipose tissue.Remove the plug, cut with sharp-sharp scissors Remove the plug, cut with sharp-sharp scissors and send for pathologyand send for pathologyUndermine if neededUndermine if neededClose with simple interrupted suturesClose with simple interrupted suturesDress and provide follow-up instructions Dress and provide follow-up instructions

Punch BiopsyPunch Biopsy

CPT – 11100 – Biopsy of skin, subcutaneous

CPT – 11101 – Biopsy of each separate or additional lesion.

Shave BiopsyShave Biopsy

Indicated for raised Indicated for raised lesion removallesion removal

Advantages – minimal Advantages – minimal time, simple, no time, simple, no suturing, generally suturing, generally good cosmetic results good cosmetic results

Shave BiopsyShave Biopsy

Consider for Consider for – skin tagsskin tags– seborrheic keratosisseborrheic keratosis– nevinevi– actinic keratosisactinic keratosis

Not indicated for Not indicated for suspected melanoma!!suspected melanoma!!

Shave Biopsy Shave Biopsy

Prep skinPrep skinLocal anesthesia to elevate lesionLocal anesthesia to elevate lesionUse #15 blade or DermaBladeUse #15 blade or DermaBladeExcise the lesion level or minimally depressed in Excise the lesion level or minimally depressed in relation to the surrounding skin. relation to the surrounding skin. Achieve hemostasis Achieve hemostasis – PressurePressure– ElectrodessicationElectrodessication– Topical agentsTopical agents

Aluminum chlorideAluminum chlorideMonsel’s solutionMonsel’s solutionSilver nitrateSilver nitrate

Submit for pathologySubmit for pathology

Shave BiopsyShave Biopsy

Shave Biopsy - DermaBladeShave Biopsy - DermaBlade

CPT – Depends on site and size.11300 – Trunk, arm, leg < 0.6 cm11301 - Trunk, arm, leg 0.6 – 1.0 cmMany others, see CPT code book.

Elliptical ExcisionElliptical Excision

Used when lesion is too large for punchUsed when lesion is too large for punchRemoves full thickness lesionRemoves full thickness lesionMajor stepsMajor steps– PlanningPlanning– AnesthesiaAnesthesia– IncisionIncision– UnderminingUndermining– HemostasisHemostasis– ClosureClosure

Planning the Elliptical Excision Planning the Elliptical Excision

Avoid vital structures! Know anatomy!Avoid vital structures! Know anatomy!Know Kraissel’s lines and plan accordinglyKnow Kraissel’s lines and plan accordinglyIncisional margin 3x diameter of lesionIncisional margin 3x diameter of lesionAnesthesia Anesthesia Incision with # 15 blade perpendicular to Incision with # 15 blade perpendicular to the skin surface through epidermis and the skin surface through epidermis and dermisdermisUndermine to allow closure of the incised Undermine to allow closure of the incised area area

Surgical BladesSurgical Blades

Elliptical ExcisionElliptical Excision

Hemostasis – pressure, electrocautery, Hemostasis – pressure, electrocautery, local anesthesia with epinephrine if local anesthesia with epinephrine if indicated!!!!indicated!!!!

Wound closure – vertical mattress, 2 layer Wound closure – vertical mattress, 2 layer closure, single layer closure.closure, single layer closure.

Send specimen for pathologySend specimen for pathology

Elliptical ExcisionElliptical Excision

Remember………… Skin tension lines!!!!

Elliptical Elliptical ExcisionExcision

Elliptical Elliptical ExcisionExcision

CPT – 11400 – Benign excision, TAL. < 0.6 cm

CPT - 11401 – Benign excision.TAL 0.6 – 1.0 cm

Additional CPT depending on size and location.

Common Office ProcedCommon Office Proceduresures ReferencesReferences

American Heart Association (2007, April 19).  Prevention of American Heart Association (2007, April 19).  Prevention of Infective Endocarditis: Guidelines From the American Infective Endocarditis: Guidelines From the American Heart Association, by the Committee on Rheumatic Heart Association, by the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease. Fever, Endocarditis, and Kawasaki Disease. Circulation Circulation 

Buttaravoli, P (2012) Buttaravoli, P (2012) Minor Emergencies. Splinters to Minor Emergencies. Splinters to Fractures, 3rd Edit. Fractures, 3rd Edit. MosbyMosby

Blair, RE (2007, March) “Surgical Management of Soft Blair, RE (2007, March) “Surgical Management of Soft Tissue MRSA Abscesses”, Tissue MRSA Abscesses”, Family Physician NewsFamily Physician News

Mayeaux, EJ (2009)The Essential Guide to Primary Care Mayeaux, EJ (2009)The Essential Guide to Primary Care Procedures. Wolters/Lippincott/Williams &Wilkins Procedures. Wolters/Lippincott/Williams &Wilkins

Pfenninger, JL (2011) Pfenninger, JL (2011) Procedures for Primary Care, 3rd Procedures for Primary Care, 3rd Edition:Edition: Mosby Mosby

Trott, AT (2012) Trott, AT (2012) Wounds and Lacerations, 4th Edit.Wounds and Lacerations, 4th Edit. Mosby Mosby