AUC Macros: Procedure

Procedure Burn

Burn treatment to ___
Irrigated affected area with normal saline
Silver sulfadiazine cream 1% applied and covered with fine mesh gauze
Rx: silver sulfadiazine cream, apply bid for 7 days
discussed proper wound care
f/u 3 days for wound check.

Procedure Cryotherapy

CRYOTHERAPY PROCEDURE NOTE

Consent: Risks and benefits of therapy discussed with patient who voices understanding and agrees with planned care. No barriers to communication or understanding identified. After obtaining informed consent, the patient's identity, procedure, and site were verified during a pause prior to proceeding with the minor surgical procedure as per universal protocol recommendations.

After appropriate cleansing, liquid nitrogen was applied to warts on ***location/size/description of wart removed***. ***Wart was/Warts were/Condylomata acuminata was/Plantar wart was/Plantar warts were*** treated with ***light cryotherapy using cotton tipped applicator/cryocautery with freeze thaw freeze technique with 2-3 mm surround freeze/shave excision of overlying keratin and then cryocauterized with freeze thaw freeze technique with 2-3 mm surround freeze/curettage/Podophylin/trichloroacetic acid***.

Education: Aftercare, including blister formation, risks of bleeding, and risks of recurrence were discussed. All questions answered. Return for re-treatment and/or recheck in 7 days.

Procedure I&D

PRE-OP DIAGNOSIS: subcutaneous abscess and cellulitis
POST-OP DIAGNOSIS: Same
PROCEDURE: incision and drainage of abscess
Performing Provider:
Supervising Physician (if applicable): _

PROCEDURE:
The procedure was explained and consent was obtained. A timeout protocol was performed prior to initiating the procedure. The area was prepared and draped in the usual, sterile manner. The site was anesthetized with _% lidocaine with epinephrine. A linear incision along the local skin lines was made and the purulent material expressed. The abscess was explored thoroughly and sequestered pockets were opened. Bleeding was minimal.
Packing: _

Followup: The patient tolerated the procedure well without complications. Standard post-procedure care is explained and return precautions are given.

Procedure injection

Precautions: The patient was asked if diabetic. The patient is currently not on any antibiotics nor suffering from any chronic infections. The patient has never had a bad reaction or an allergic reaction to local anesthetic or corticosteroid.
Prep: alcohol and chlorhexidine
Site:
Side:
Medication: Lidocaine 2% w/o epi and 40mg Kenalog
Needle: 27g 1/2 inch
Results: no response
Complications: none
Ultrasound: for needle guidance and identification of correct anatomical location.
Response: Pt tolerated the procedure well.
Aftercare instructions: The patient was instructed to watch for increasing redness, swelling, heat to the affected area. The patient is instructed to watch for development of fever, chills, nausea, vomiting or any signs that make the patient believe there is a developing or active infection. If any of these conditions exist, the patient is instructed to go for care immediately to primary care, urgent care or emergency room, whichever is most convenient and appropriate. Pt acknowledges understanding and agrees to comply. The patient is educated on possible adverse effects of corticosteroids to include headache, facial flushing, heart palpitations, anxiety, insomnia, weight gain, increased appetite, aggressive mood. The patient is reassured that the symptoms are temporary and will dissipate as treatment they is farther away, but is encouraged to contact the clinic if there is any concern. Patient acknowledges understanding and agrees to comply.agrees to comply.

PROCEDURE IVF therapy

IV started at XX:XX after prepared; no air bubble seen in line. PA/NP initiated the line on R/L AC bolus. No signs of infiltration observed and pt tolerated well.
The drip ended at XX:XX and shortly catheter was removed from the site without issues. Applied pressure for few minutes until good hemostasis achieved; the IV site was dressed and reminded pt to leave dressing for an hour.

Procedure: joint injection

PROCEDURE:
Risks and benefits were discussed with the patient. The patient agrees with the plan and would like to proceed with the injection. The *** joint was prepped with alcohol. 2cc or Kenalog and 2cc of Lidocaine were injected into the joint using ***posterior port. Patient tolerated the procedure well.

Procedure laceration NAV

PROCEDURE: laceration repair
The area was prepped with Betadine and a sterile field was established with a fenestrated drape. *** lidocaine was injected. Once adequate anesthesia achieved, *** stitches were placed with ETHILON X.0. Patient tolerated the procedure well. Triple antibiotic ointment, non-adhesive dressing, rolled gauze, and coban applied.

TDAP UPTD
Prescription sent for ATB
OTC Tylenol/advil prn for pain
f/u 72 hours for wound check
sooner if needed.

Procedure Ortho glass splint

PROCEDURE: casting
fiberglass cast placed on *** with adequately padding. Patient tolerated the procedure well. Patient was able to more ***fingers/toes after the application. Post casting exam done and is neurovascularly intact. Patient was given care instructions on keeping the cast dry. Patient will follow up in 3 weeks if not sooner as necessary. Patient was told that if something does happen with the cast that they are to call immediately and we will see them back in clinic.

Procedure Ortho splint- MC

PROCEDURE: Splint
Indication:
Type:
Wounds: no abrasions or lacerations underneath splint
Neurovascular status: patient has sensation and movement of digits extending outside the splint, there is no cyanosis, NV intact.

Procedure Scalp Steroid Inject

Informed Consent: The pt was informed of the risk of skin atrophy and discoloration and informed of alternative treatment options including topical steroids. Despite these risks, the pt chose to proceed with the procedure.

PROCEDURE: The area was first covered in topical lidocaine. This was allowed to take effect before iodine was used to disinfect the area. 0.75 mL of 10 mg/mL of triamcinolone was diluted with 2.25 mL of normal saline. 0.1 mL intradermal injections administered at 1 cm intervals In the affected areas. The pt tolerated the procedure well. Aftercare instructions provided including avoiding chemical irritants such as hair gel or other similar products.

Procedure Subungual Hematoma

Verbal consent received from the patient.

Area cleanse with sterile NS. ***Left/Right hand ***thumb/index/middle/ring/little finger subungal hematoma drained by making a small hole on the nail with electro excision tool. Large/Small/Moderate amount of blood drained, Patient verbalized pain and pressure relieved. Able to move the joint after procedure. Apply ice and elevate the digit during the first 24 to 48 hours to reduce soft tissue swelling and oral analgesia.

Oral Antibiotic Therapy:

***Nail is going to come off, patient understands the plan of care.

Patient instructed to return for reevaluation for any of the following reasons:

●Reaccumulation of the hematoma with pain

●Signs of infection (warmth, redness, excessive swelling, fever)

F/U 4-5 Days or sooner if any evidence or infection or worsening pain.

Procedure splint application

fiberglass splint placed on ******* with adequately padding and alignment. Patient tolerated the procedure
well. Patient was able to move fingers/toes after the application. Post splinting exam done and is neurovascularly intact. Patient was given care instructions on keeping the splint dry. Patient will follow up 2-3 days if not sooner as necessary. Patient was told that if something does happen with the splint that they
have to call immediately and we will see them back in clinic.

Procedure Toenail Removal

PRE-OP DIAGNOSIS: cellulitis right great toe with paronychia
POST-OP DIAGNOSIS: Same
PROCEDURE: partial excision of toenail
Performing Provider: Clark Bishop PA-C
Supervising Physician (if applicable): _

PROCEDURE:
A timeout protocol was performed prior to initiating the procedure. The area was prepared and draped in the usual, sterile manner. The site was anesthetized via digital nerve block with 1% lidocaine without epinephrine. A linear incision along the portion of nail adjacent to infected area and the purulent material expressed. The area was explored thoroughly and any nail fragments removed. Bleeding was minimal.

Followup: The patient tolerated the procedure well without complications. Standard post-procedure care is explained and return precautions are given.

Procedure trigger point inj.

Trigger point injection procedure:
myofascial spasm was prepped with alcohol utilizing sterile technique.
OPERATION: Trigger Point Injection.
ANESTHESIA: Local and sedation.

COMPLICATIONS: None.

DESCRIPTION OF PROCEDURE: The procedure risks, hazards and alternatives were discussed with the patient and a proper consent was obtained. The area over the myofascial spasm was prepped with alcohol utilizing sterile technique. After isolating it between two palpating fingertips a 25-gauge 5" needle was placed in the center of the myofascial spasms and a negative aspiration was performed. Then 4 cc of Marcaine 0.5% was injected into each trigger point. The patient tolerated the procedure well without any apparent difficulties or complications. They were feeling relief by the time the block had set.


The patient presents with Low back pain without evidence of injury.
Given the patient's presentation and physical exam findings,There is no indication for x-ray
The patient has significant muscular tenderness to palpation and some spasm in the paraspinous musculature. The patient had no significant muscular weakness, and there were no other significant neurological findings on exam, no sensation deficit or reflex abnormalities. The patient’s exam and/or urine was not consistent with pyelonephritis and the patient is afebrile, making other infectious etiologies less likely.
The patient achieved significant relief of the symptoms with our interventions and was able to ambulate with some residual discomfort. The patient is a good candidate for outpatient symptomatic management.
I instructed the patient that back pain of this nature will take time to improve, but it often does. I did discharge the patient with oral pain medications.*** Patient was instructed to return or call primary physician with any worsening symptoms including but not limited to: numbness or weakness in the legs, bowel or bladder problems, numbness in the groin. Patient was also instructed to return or call with any worsening symptomatology or questions.

Procedure Woods lamp exam

Procedure:
The fluorescein examination is performed as follows: Applied topical tetracaine in patient's ***** eye. The lower lid is pulled down, and a fluorescein paper strip is moistened with saline. Exam conducted in dark room under UV light. Eyelid everted for any foreign bodies. Pt tolerated well. No complications.

Procedure suture removal

Suture removal
Area shows no signs of swelling or discharge
Wound single layer closure, well healed
#** stitches removed
Wound dressed appropriately

Pt advised to continue to be aware of signs of infection not limited to redness, swelling, and discharge.

RTC if needed.

Precedure Ear Lavage

Instilled 3 to 5 drops of Debrox into the affected ear and then request that the patient wait 10 minutes before flushing.
Using room temperature water mixed with hydrogen peroxide and the ear lavage equipment, gently flush the ear canal, allowing the water to collect in the basin held below the ear. Repeated until cleared.
Patient tolerated well without complains of dizziness, nausea, or pain.
Patient reported symptom improvement.
***Due to intolerability, stopped the irrigation and refer to the clinician for evaluation.

Procedure Wound care/repairYesim

IRRIGATION:
The area was cleaned with normal saline/ potable water total of 60 ml via syringe. Steady flow of a solution across an open wound surface maintained to achieve wound hydration, to remove deeper debris, surface pathogens contained in wound exudates, or residue from topically applied

PROCEDURE: laceration repair
The area was prepped with Betadine and a sterile field was established with a fenestrated drape. 6 cc 2% lidocaine was injected. Once adequate anesthesia achieved, 5 stitches were placed with ETHILON 4-0 derma bound was applied to edge of the laceration to support sutures, Patient tolerated the procedure well. Triple antibiotic ointment, non-adhesive dressing, gauze and ace band applied.

TDAP not UTD, rx send to his pharmacy.
Prescription sent for prophylactic antibiotic ( Keflex DS twice a day)
OTC Tylenol/advil prn for pain
f/u 72 hours for wound check
sooner if needed care products.
Upon completion, No foreign body observed. Patient tolerated well without issues.


*** Dermabond Adhesive is a sterile, liquid skin adhesive that holds wound edges together. The film will usually remain in place for 5 to 10 days, then naturally fall off your skin. Do not wet the area or apply liquid or ointment medications or any other product to your wound while the DERMABOND ADVANCED Adhesive is in place for at least 36 hours. These may loosen the film before your wound is healed.

You may occasionally and briefly wet your wound in the shower or bath. Do not soak or scrub your wound, do not swim, and avoid
periods of heavy perspiration until the DERMABOND ADVANCED Adhesive has naturally fallen off
• After showering or bathing, gently blot your wound dry with a soft towel. If a protective dressing is being used, apply a fresh, dry bandage, keeping the tape on the DERMABOND
• Protect your wound from injury until the skin has had sufficient time to heal
• Do not scratch, rub, or pick at the DERMABOND ADVANCED Adhesive. This may loosen the film before your wound is healed
• Protect the wound from prolonged exposure to sunlight or tanning lamps while the film is in place.

***COUNSELING:The patient presents with laceration(s) as described in PE. On exam there was no definitive evidence for associated complications such as tendon, nerve or arterial compromise. I discussed the possibility of residual foreign body with patient and that no matter how thorough the search it is still a possibility. I explained to return with any thought of retained FB.I also explained what to look for with regard to infection. The patient agreed to call/return with any increasing discharge, extending erythema, fever, nausea/vomiting or any other changes.

I also discussed the inevitability of scarring with the patient. They understand that all lacerations will leave a varying degree of scarring and optimal outcome/cosmetic appearance can never be guaranteed. They also understand the possibility of revision by plastic surgery in the future if deemed necessary.

****EMERGENCY and RETURN PRECAUTIONS: worsening symptoms, bleeding, infection signs, warmth, redness, drainage from the wound, fever, chills, extremity pain or swelling, numbness, tingling, weakness, cp, sob, dizziness, abdominal pain, blood in stool, any medication side effect or other concerns.
FU in 2-3 days or earlier if any concern.
patient voiced understanding and agreed with the plan.

PROCEDURE Needle aspiration

Procedure: Verbal consent obtained.
Needle aspiration

Type: abscess
Location details:
Local anesthetic: lidocaine ***% with/ w/o epinephrine
Anesthetic total: *** ml
Needle size: ***
Complexity: simple
Drainage: *** purulent
Drainage amount: ***moderate
Patient tolerance: Patient tolerated the procedure well with no immediate complications.

PROCEDURE Foley catheter removal

Procedure: Verbal consent obtained.
Urinary catheter removal

STATLOCK® Foley device and taping were removed from the thigh. Patient in standing position to allow emptying the bladder and placed waterproof pad under patient. The catheter balloon was deflated with 10cc syringe via the inflation port by allowing the pressure within the balloon to force the plunger back and fill the syringe with water (if slow or no deflation is noticed, re-seat the syringe gently). Gentle aspiration to encourage deflation if needed as vigorous aspiration may collapse the inflation lumen, preventing balloon deflation.
Upon complete deflation of catheter balloon, Foley catheter was pulled gently and discarded.

Pt was able to void without catheter in the clinic without issues. Pt tolerated the procedure well.