solocoder
Expert
Could I please get some opinions on the LOS for this visit?
Thanks.
Patient presents today with complaints of a painful right hallux toenail. She underwent a P & A on both borders of both hallux nails in June and states the lateral border of the right hallux has grown back and is painful. She has been trimming it short but it is not helping. She has no other complaints.
REVIEW OF SYSTEMS: as reported by patient on this date, is as follows:
INTEGUMENTARY: Ingrown toenail
CONSTITUTIONAL: Negative.
MUSCULOSKELETAL: Negative.
NEUROLOGICAL: Negative.
Filed Vitals:
02/26/13 1326
BP: 143/91
Pulse: 78
Height: 5' 3" (1.6 m)
Weight: 145 lb (65.772 kg)
VASCULAR: Revealed pulses of 2/4 for dorsalis pedis bilaterally and 2/4 for posterior tibial bilaterally. Subcapillary venous filling time was noted to be immediate.
NEUROLOGICAL: Non-contributory.
ORTHOPEDIC: No pain was noted on passive range of motion of the areas.
DERMATOLOGICAL: Revealed painful, inflammed, ingrown nail was noted on rightl hallux, lateral border . Mild erythema was noted on the border. There was no sign of active drainage or cellulitis noted. No sign of acute infection noted.
ASSESSMENT:
Onychocryptosis, right hallux, lateral border
PLAN:
Discussed conservative versus surgical treatment methods. The surgical procedure for Phenol & Alcohol Matricectomy was explained to the patient in detail, including, but not limited to regrowth of the nail or a portion there of, infection, continued or recurrent pain, granulomatous cyst, etc. Following written and verbal consent the digit was anesthetized with 5 cc of a 50/50 mixture of 2 % lidocaine and 0.5 % marcaine plan. After a sterile prep the offending border was freed from the nail bed, the eponychium and the hyponychium. The border was trimmed back to the level of the matrix then grasped with a hemostat and removed from the surgical field. Three applications of phenol times 30 seconds were then applied. Following irrigation with alcohol a sterile compressive dressing was applied. The patient was given home going instructions including soaking and the signs and symptoms of infection were discussed as well. She was instructed to call the office should she experience these. She will follow up to the clinic in two weeks for a nail check.
Thanks.
Patient presents today with complaints of a painful right hallux toenail. She underwent a P & A on both borders of both hallux nails in June and states the lateral border of the right hallux has grown back and is painful. She has been trimming it short but it is not helping. She has no other complaints.
REVIEW OF SYSTEMS: as reported by patient on this date, is as follows:
INTEGUMENTARY: Ingrown toenail
CONSTITUTIONAL: Negative.
MUSCULOSKELETAL: Negative.
NEUROLOGICAL: Negative.
Filed Vitals:
02/26/13 1326
BP: 143/91
Pulse: 78
Height: 5' 3" (1.6 m)
Weight: 145 lb (65.772 kg)
VASCULAR: Revealed pulses of 2/4 for dorsalis pedis bilaterally and 2/4 for posterior tibial bilaterally. Subcapillary venous filling time was noted to be immediate.
NEUROLOGICAL: Non-contributory.
ORTHOPEDIC: No pain was noted on passive range of motion of the areas.
DERMATOLOGICAL: Revealed painful, inflammed, ingrown nail was noted on rightl hallux, lateral border . Mild erythema was noted on the border. There was no sign of active drainage or cellulitis noted. No sign of acute infection noted.
ASSESSMENT:
Onychocryptosis, right hallux, lateral border
PLAN:
Discussed conservative versus surgical treatment methods. The surgical procedure for Phenol & Alcohol Matricectomy was explained to the patient in detail, including, but not limited to regrowth of the nail or a portion there of, infection, continued or recurrent pain, granulomatous cyst, etc. Following written and verbal consent the digit was anesthetized with 5 cc of a 50/50 mixture of 2 % lidocaine and 0.5 % marcaine plan. After a sterile prep the offending border was freed from the nail bed, the eponychium and the hyponychium. The border was trimmed back to the level of the matrix then grasped with a hemostat and removed from the surgical field. Three applications of phenol times 30 seconds were then applied. Following irrigation with alcohol a sterile compressive dressing was applied. The patient was given home going instructions including soaking and the signs and symptoms of infection were discussed as well. She was instructed to call the office should she experience these. She will follow up to the clinic in two weeks for a nail check.