arkolab
Contributor
Does the below encounter support billing an EM with the toenail removal? Patient has been seen for this in family med but now being referred to podiatry for further evaluation.
Chief Complaint
Patient presents with
• Toenail
Right Great toe
History of Present Illness: Patient is a 61-year-old male who presents to clinic for a complaint of right great toe pain. The patient tells me that he has pain along the medial nail fold to the right great toe. He has had troubles with this area for years, maybe decades. He states that he will commonly develop pain along the medial border and he will cut back his nail rather aggressively and peel out some of the associated skin. He states that this improves his symptoms for a few months until his symptoms recur. He does not endorse trauma to the right great toe years ago that resulted in loss of the nail. He states that he recently had remove the nail and does not present with pain today however this has become an ongoing issue for him. He denies any recent purulence, redness, swelling to the area. He was evaluated by his primary care physician, Dr. xxx, MD who referred him to our service for further management. He would like to discuss more permanent options for this issue.
History:
CURRENT MEDICATIONS:
Current Outpatient Medications
Medication Sig
• atorvastatin (Lipitor) 10 MG tablet Take 1 (one) tablet by mouth once daily
• clotrimazole-betamethasone (Lotrisone) 1-0.05 % cream APPLY EXTERNALLY TO THE AFFECTED AREA TWICE DAILY AS NEEDED
• hydrocortisone (Anucort-HC) 25 MG suppository Insert 1 (one) suppository into the rectum 2 times daily as needed for Hemorrhoids
• loratadine (CLARITIN) 10 MG tablet Take 1 (one) tablet by mouth once daily
• montelukast (Singulair) 10 MG tablet Take 1 (one) tablet by mouth at bedtime
• multivitamin daily tablet Take 1 (one) tablet by mouth daily with food
• pimecrolimus (Elidel) 1 % cream Apply 2 times daily As needed.
• rizatriptan, disintegrating, (Maxalt MLT) 10 MG tablet Take 1 (one) tablet by mouth daily as needed - may repeat one time (Migraine)
• Saw Palmetto, Serenoa repens, 160 MG Take 2 (two) capsules by mouth once daily
• tobramycin-dexAMETHasone (Tobradex) 0.3-0.1 % ophthalmic ointment Instill into both eyes 2 times daily
• vitamin D3 (CHOLECALCIFEROL) 1000 UNITS tablet Take 2 (two) tablets by mouth once daily
No current facility-administered medications for this visit.
ALLERGIES:
Penicillins, Plavix [clopidogrel], and Mycobacterium
PAST MEDICAL HISTORY:
No past medical history on file.
Past Surgical History:
Procedure Laterality Date
• COLONOSCOPY 06/2014
normal, done in Illinois
• ORAL SURGERY N/A
• OTHER SURGERY
Bone spur procedure
Family History
Problem Relation Name Age of Onset
• Cataract Mother
• Cataract Father
• Cancer - Skin, Non Melanoma Father
• None Known Sister
• None Known Brother
Social History
Socioeconomic History
• Marital status: Married
Spouse name: Not on file
• Number of children: Not on file
• Years of education: Not on file
• Highest education level: Not on file
Occupational History
• Not on file
Tobacco Use
• Smoking status: Never
• Smokeless tobacco: Never
Vaping Use
• Vaping status: Never Used
Substance and Sexual Activity
• Alcohol use: No
• Drug use: No
• Sexual activity: Yes
Partners: Female
Other Topics Concern
• Not on file
Social History Narrative
• Not on file
Social Determinants of Health
Financial Resource Strain: Low Risk (11/15/2024)
Overall Financial Resource Strain (CARDIA)
• Difficulty of Paying Living Expenses: Not hard at all
Food Insecurity: No Food Insecurity (11/15/2024)
Hunger Vital Sign
• Worried About Running Out of Food in the Last Year: Never true
• Ran Out of Food in the Last Year: Never true
Transportation Needs: No Transportation Needs (11/15/2024)
PRAPARE - Transportation
• Lack of Transportation (Medical): No
• Lack of Transportation (Non-Medical): No
Stress: No Stress Concern Present (11/15/2024)
Finnish Institute of Occupational Health - Occupational Stress Questionnaire
• Feeling of Stress : Not at all
Housing Stability: Low Risk (11/15/2024)
Housing Stability Vital Sign
• Unable to Pay for Housing in the Last Year: No
• Number of Times Moved in the Last Year: 1
• Homeless in the Last Year: No
Review of Systems:
(For the following ROS, pertinent positives are in bold; pertinent negatives are in italics.)
CONSTITUTIONAL: fevers, chills, night sweats, weight loss, fatigue
CV: chest pain, dyspnea, palpitations, orthopnea, PND, LE swelling, change in ET status
RESP: cough, dyspnea, hemoptysis
GI: abdominal pain, nausea, vomiting, diarrhea, constipation, melena
MSKL: right great toe pain. pain cervical/thoracic/lumbar, muscle weakness, muscle pain, joint pain, joint swelling, decreased ROM
SKIN: rash, pain, pruritis, lesions, lumps, skin breakdown, jaundice, ecchymosis
NEURO: headache, dizziness, LOC, weakness, paresthesias, gait problems, lightheadedness, slurred speech
BEHAVIOR: appetite change, sleep disturbances, changes in energy level, poor concentration, depressed mood, fatigue, agitation, anxiety
Physical Examination:
Vitals:
12/09/24 0910
Pulse: 73
SpO2: 98%
Lower extremity exam:
Vasc: DP and PT pulses palpable, bilateral. CFT less than 3 seconds to all digits, bilateral. no varicosities noted, bilateral. Pedal hair growth present. Skin temperature is warm to warm proximal to distal bilateral.
Neuro: Monofilament exam is intact distal to ankle, bilateral. Vibratory sensation is intact, bilateral. Achilles reflex is 1/4, bilateral. Tinel's sign negative.
Musculoskeletal: Manual muscle strength testing is 5/5 bilaterally to all lower extremity muscle groups. Digital contractures present digits 4 and 5 bilaterally. First MPJ ROM nonpainful bilateral. Subtalar joint and ankle joint ROM nonpainful bilateral. Pain on palpation along the medial nail fold right great toe. Equinus deformity present bilateral.
Dermatologic: Skin texture is within normal limits. Ingrowing nail to the medial border right great toenail. No surrounding erythema, no purulence, no localized edema. no edema noted, bilateral. Hemosiderin absent bilaterally.
Impression/Plan:
1. Great toe pain, right
2. Ingrown right greater toenail
Patient seen and examined. All questions and concerns were addressed to patient satisfaction.
An annual lower extremity risk assessment was performed today. pt was educated that the patient is a low risk (group 1). pt risk factors include foot deformities. We also discussed the importance of proper foot care and protective shoe gear. The patient is to perform daily foot checks and call us immediately if issues arise.
pt was educated on treatment options for ingrown toenails. Both temporary and permanent procedures were explained to them. We did discuss risks, benefits and alternatives of these procedures. The patient selected a permanent removal. The patient was educated that risks of this procedure include recurrence, infection and over burn.
Procedure note:
A timeout was performed to confirm the correct site, patient, procedure, and we confirmed that we had all the necessary material on site. Consent was obtained from the patient. Local anesthesia was obtained to the affected area. The medial nail plate from the right hallux was removed. The site was inspected and no remaining debris or spicule was noted within the surgical site. A matrixectomy was performed chemically using phenol and mechanically using a rasp. A dry, sterile dressing was then applied. Pt was educated to leave the dressing intact until tomorrow morning at which they will begin local wound care. Both written and verbal instructions were provided.
The patient received a prescription for corticosporin otic drops which they are to use twice daily as instructed. It was discussed with the patient that they may do activities as tolerated and wear shoe gear as tolerated. pt is to take over-the-counter anti-inflammatory or acetaminophen for pain management.
pt will be reevaluated in 3 weeks to assess the postoperative progress. If the patient sees full resolution and healing of the surgical site, pt is to cancel the appointment and follow-up as needed. If problems or questions arise, the patient is to call.
Orders Placed This Encounter
• neomycin-polymyxin-hc (Cortisporin) 3.5-10000-1 otic suspension
Sig: Apply 2 (two) drops to affected area 2 times daily for 7 days Apply 2 drops to the hallux procedure site twice daily
Dispense: 10 mL
Refill: 0
Chief Complaint
Patient presents with
• Toenail
Right Great toe
History of Present Illness: Patient is a 61-year-old male who presents to clinic for a complaint of right great toe pain. The patient tells me that he has pain along the medial nail fold to the right great toe. He has had troubles with this area for years, maybe decades. He states that he will commonly develop pain along the medial border and he will cut back his nail rather aggressively and peel out some of the associated skin. He states that this improves his symptoms for a few months until his symptoms recur. He does not endorse trauma to the right great toe years ago that resulted in loss of the nail. He states that he recently had remove the nail and does not present with pain today however this has become an ongoing issue for him. He denies any recent purulence, redness, swelling to the area. He was evaluated by his primary care physician, Dr. xxx, MD who referred him to our service for further management. He would like to discuss more permanent options for this issue.
History:
CURRENT MEDICATIONS:
Current Outpatient Medications
Medication Sig
• atorvastatin (Lipitor) 10 MG tablet Take 1 (one) tablet by mouth once daily
• clotrimazole-betamethasone (Lotrisone) 1-0.05 % cream APPLY EXTERNALLY TO THE AFFECTED AREA TWICE DAILY AS NEEDED
• hydrocortisone (Anucort-HC) 25 MG suppository Insert 1 (one) suppository into the rectum 2 times daily as needed for Hemorrhoids
• loratadine (CLARITIN) 10 MG tablet Take 1 (one) tablet by mouth once daily
• montelukast (Singulair) 10 MG tablet Take 1 (one) tablet by mouth at bedtime
• multivitamin daily tablet Take 1 (one) tablet by mouth daily with food
• pimecrolimus (Elidel) 1 % cream Apply 2 times daily As needed.
• rizatriptan, disintegrating, (Maxalt MLT) 10 MG tablet Take 1 (one) tablet by mouth daily as needed - may repeat one time (Migraine)
• Saw Palmetto, Serenoa repens, 160 MG Take 2 (two) capsules by mouth once daily
• tobramycin-dexAMETHasone (Tobradex) 0.3-0.1 % ophthalmic ointment Instill into both eyes 2 times daily
• vitamin D3 (CHOLECALCIFEROL) 1000 UNITS tablet Take 2 (two) tablets by mouth once daily
No current facility-administered medications for this visit.
ALLERGIES:
Penicillins, Plavix [clopidogrel], and Mycobacterium
PAST MEDICAL HISTORY:
No past medical history on file.
Past Surgical History:
Procedure Laterality Date
• COLONOSCOPY 06/2014
normal, done in Illinois
• ORAL SURGERY N/A
• OTHER SURGERY
Bone spur procedure
Family History
Problem Relation Name Age of Onset
• Cataract Mother
• Cataract Father
• Cancer - Skin, Non Melanoma Father
• None Known Sister
• None Known Brother
Social History
Socioeconomic History
• Marital status: Married
Spouse name: Not on file
• Number of children: Not on file
• Years of education: Not on file
• Highest education level: Not on file
Occupational History
• Not on file
Tobacco Use
• Smoking status: Never
• Smokeless tobacco: Never
Vaping Use
• Vaping status: Never Used
Substance and Sexual Activity
• Alcohol use: No
• Drug use: No
• Sexual activity: Yes
Partners: Female
Other Topics Concern
• Not on file
Social History Narrative
• Not on file
Social Determinants of Health
Financial Resource Strain: Low Risk (11/15/2024)
Overall Financial Resource Strain (CARDIA)
• Difficulty of Paying Living Expenses: Not hard at all
Food Insecurity: No Food Insecurity (11/15/2024)
Hunger Vital Sign
• Worried About Running Out of Food in the Last Year: Never true
• Ran Out of Food in the Last Year: Never true
Transportation Needs: No Transportation Needs (11/15/2024)
PRAPARE - Transportation
• Lack of Transportation (Medical): No
• Lack of Transportation (Non-Medical): No
Stress: No Stress Concern Present (11/15/2024)
Finnish Institute of Occupational Health - Occupational Stress Questionnaire
• Feeling of Stress : Not at all
Housing Stability: Low Risk (11/15/2024)
Housing Stability Vital Sign
• Unable to Pay for Housing in the Last Year: No
• Number of Times Moved in the Last Year: 1
• Homeless in the Last Year: No
Review of Systems:
(For the following ROS, pertinent positives are in bold; pertinent negatives are in italics.)
CONSTITUTIONAL: fevers, chills, night sweats, weight loss, fatigue
CV: chest pain, dyspnea, palpitations, orthopnea, PND, LE swelling, change in ET status
RESP: cough, dyspnea, hemoptysis
GI: abdominal pain, nausea, vomiting, diarrhea, constipation, melena
MSKL: right great toe pain. pain cervical/thoracic/lumbar, muscle weakness, muscle pain, joint pain, joint swelling, decreased ROM
SKIN: rash, pain, pruritis, lesions, lumps, skin breakdown, jaundice, ecchymosis
NEURO: headache, dizziness, LOC, weakness, paresthesias, gait problems, lightheadedness, slurred speech
BEHAVIOR: appetite change, sleep disturbances, changes in energy level, poor concentration, depressed mood, fatigue, agitation, anxiety
Physical Examination:
Vitals:
12/09/24 0910
Pulse: 73
SpO2: 98%
Lower extremity exam:
Vasc: DP and PT pulses palpable, bilateral. CFT less than 3 seconds to all digits, bilateral. no varicosities noted, bilateral. Pedal hair growth present. Skin temperature is warm to warm proximal to distal bilateral.
Neuro: Monofilament exam is intact distal to ankle, bilateral. Vibratory sensation is intact, bilateral. Achilles reflex is 1/4, bilateral. Tinel's sign negative.
Musculoskeletal: Manual muscle strength testing is 5/5 bilaterally to all lower extremity muscle groups. Digital contractures present digits 4 and 5 bilaterally. First MPJ ROM nonpainful bilateral. Subtalar joint and ankle joint ROM nonpainful bilateral. Pain on palpation along the medial nail fold right great toe. Equinus deformity present bilateral.
Dermatologic: Skin texture is within normal limits. Ingrowing nail to the medial border right great toenail. No surrounding erythema, no purulence, no localized edema. no edema noted, bilateral. Hemosiderin absent bilaterally.
Impression/Plan:
1. Great toe pain, right
2. Ingrown right greater toenail
Patient seen and examined. All questions and concerns were addressed to patient satisfaction.
An annual lower extremity risk assessment was performed today. pt was educated that the patient is a low risk (group 1). pt risk factors include foot deformities. We also discussed the importance of proper foot care and protective shoe gear. The patient is to perform daily foot checks and call us immediately if issues arise.
pt was educated on treatment options for ingrown toenails. Both temporary and permanent procedures were explained to them. We did discuss risks, benefits and alternatives of these procedures. The patient selected a permanent removal. The patient was educated that risks of this procedure include recurrence, infection and over burn.
Procedure note:
A timeout was performed to confirm the correct site, patient, procedure, and we confirmed that we had all the necessary material on site. Consent was obtained from the patient. Local anesthesia was obtained to the affected area. The medial nail plate from the right hallux was removed. The site was inspected and no remaining debris or spicule was noted within the surgical site. A matrixectomy was performed chemically using phenol and mechanically using a rasp. A dry, sterile dressing was then applied. Pt was educated to leave the dressing intact until tomorrow morning at which they will begin local wound care. Both written and verbal instructions were provided.
The patient received a prescription for corticosporin otic drops which they are to use twice daily as instructed. It was discussed with the patient that they may do activities as tolerated and wear shoe gear as tolerated. pt is to take over-the-counter anti-inflammatory or acetaminophen for pain management.
pt will be reevaluated in 3 weeks to assess the postoperative progress. If the patient sees full resolution and healing of the surgical site, pt is to cancel the appointment and follow-up as needed. If problems or questions arise, the patient is to call.
Orders Placed This Encounter
• neomycin-polymyxin-hc (Cortisporin) 3.5-10000-1 otic suspension
Sig: Apply 2 (two) drops to affected area 2 times daily for 7 days Apply 2 drops to the hallux procedure site twice daily
Dispense: 10 mL
Refill: 0
