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Procedure Notes

PROCEDURE:   AURICULAR BLOCK

 

         Because of the trauma to the ear, and the need to anesthetize it, the patient underwent an auricular block of the LEFT   ear.

 

           The area around the ear was cleansed with an alcohol pads. Then utilizing a sterile 27-gauge needle, I then infiltrated the anterior aspect of the ear; just superior and anterior to the tragus to anesthetize the auriculotemporal nerve.  I then did also anesthetized the posterior aspect of the ear [behind the auricle], to anesthetize the greater auricular nerve.  A total of approximately 6 mls of 0.5% Sensorcaine was utilized for this procedure.  The patient tolerated the procedure well, and had good anesthetic effect of the ear.

 

 

PROCEDURE:   Bartholin Gland Abscess

 

Patient had a Bartholin gland abscess on the ________  side of her vagina. It was tender and appears to be fluctuant thus we proceed with incision and drainage. The area was prepped and cleansed, and then the inner aspect of the mucosal region was anesthetized with Sensorcaine. Then using a #11 blade scalpel we cut into the most fluctuant area and tried to drain as much pus from the area as possible.

 

Because a Word catheter was not readily available, but utilized normal packing inside the wound. This will need to be removed in about 2 or 3 days. She may return here for any questions or any problems as we discussed.

 

Overall the patient tolerated the procedure well. 

 

PROCEDURE:    BILATERAL MENTAL BLOCK

 

This patient underwent regional block of the bilateral mental nerves, on the lower mandible. This was done to adequately anesthetize the whole area. Utilizing Sensorcaine 0.5% with epinephrine, and a 27-gauge needle, I introduced the needle through the mucosal surface of the bilateral lower, lateral incisor teeth. I proceeded to the area where the mental nerve emerges on both sides and infiltrated approximately 2-3 mls on both sides. After a few minutes, the patient had a very good lower-mandible, regional block.

 

PROCEDURE: CENTRAL LINE

 

This patient had a central line placed. The indication was the need to secure intravenous access for resuscitation.

 

Per protocol, a time out was performed prior to the procedure. If applicable, consent was obtained, and the potential risks and advantages as well as other alternatives were considered prior to this procedure.

 

We utilized masks, as well as sterile gowns sterile gloves. Then the patient was prepped in a sterile fashion.  The central line catheter was flushed with sterile saline.

 

Utilizing an ultrasound probe with a sterile cover, the RIGHT INTERNAL JUGULAR vein was identified. Then utilizing the introducer needle, we then cannulized the INTERNAL JUGULAR vein. Dark venous blood return was obtained. Then utilizing a Seldinger technique, the guide wire was fed, followed by the central line. Blood was returned easily and the line also easily flushed.  The line was then sutured using sutures followed by a sterile dressing. Placement was confirmed with a portable chest x-ray. The patient tolerated the procedure well.

 

PROCEDURE cerumen removal:

 

Patient had a significant amount of cerumen in both ear canals.    Using a cerumen spoon, I carefully removed as much of the cerumen as I could.

 

There was no TM perforation, and no bleeding.  Patient tolerated the procedure without difficulty.

 

 

PROCEDURE:       B/L Cervical Block for HEADACHE

 

Initially, I had the patient sit up on the side of the bed looking straight forward. I then identified and the landmarks at the C6 and C7 spinous levels, and thoroughly cleaned the areas with alcohol pads. Then utilizing 0.5% Sensorcaine plain, I then introduced a 27-gauge needle approximately 1 1/4 inch horizontally and lateral to the spine. My angle was basically parallel to the floor. I then instilled approximately 2 mls of Sensorcaine initially on the right side, and then on the left side. Band-Aids were placed over the insertion sites. The patient was reevaluated shortly thereafter with some improvement and had no obvious complications from the procedure.

 

PROCEDURE:  CORING OF FOOT.

 

            The patient and I were both concerned that there was a foreign body in the foot.  X-rays were obtained. With the patient's permission, the area on the foot was prepped with Betadine. Then it was anesthetized using Sensorcaine with epinephrine. The area was then prepped in a sterile fashion. In a sterile technique utilizing a #11 blade scalpel, I then cored the area around where the foreign body penetration area was. Bleeding was only minimal. Patient tolerated the procedure well.  A dressing was placed.

 

             Patient was given verbal instructions of what to do and what to look for. I could not guarantee that all foreign body particulate matter was removed. And if the patient were to develop an infection over the next few weeks or month or 2, there may be indicative that there is still some retained foreign body in there that may require definitive operative management.

 

 

 

PROCEDURE:   DRAINAGE  OF DENTAL ABSCESS  (tooth # ___ )

 

After a local dental block utilizing Sensorcaine with epinephrine, I then used a sterile 18-gauge needle to open up the most fluctuant area.  I then expressed pus from the area, followed by irrigation, with the patient doing rinse and spit in to the sink

 

The patient tolerated the procedure well, was started on antibiotics, and given written and verbal instructions.  They were instructed to follow up with a dentist ASAP. They're to return here if her condition worsens as we discussed.

 

PROCEDURE -- DIGITAL BLOCK:

              

                 Patient underwent a digital block using Sensorcaine plain. The volar aspect of the proximal phalanx was cleansed. Then I utilized approximately 2 mls of Sensorcaine 0.5% onto both sides of the phalanx to induce a digital block. Patient tolerated the procedure well and had very good analgesic effect with this procedure.

 

PROCEDURE:      EAR WICK PLACEMENT in  RIGHT  ear

 

Because the patient has significant otitis externa with significant swelling, I initially placed Auralgon into the ear canal help with his local pain. Then, using a gloved hand, I then proceeded to place the ear wick directly into the ear canal.  I ensured that it was in far enough to allow absorption of the antibiotic through the entire length of the ear canal. Although the patient did have some mild discomfort with this, the procedure was otherwise tolerated well.  No evidence of TM perforation or bleeding.

 

I recommended that the patient avoid water in the ear for about a week or until better. In addition, I recommended that they avoid Q-tip use as this can contribute to this problem as well.

 

Finally, I explained to the patient/guardian that the ear wick needs to be removed in about 2 or 3 days.  Options include coming back here, or following up with their primary care physician.  They are to return to this ED, if they have any problems or complications as we discussed.

 

Procedure:   ENDOTRACHEAL INTUBATION (elective)

 

                The benefits, risks, and alternatives were discussed with the patient, parent, and/or guardian. An opportunity to ask questions was provided, and consent was given for the procedure.  The patient was pre-oxygenated as best as possible.  Suction was ready.  The patient was sedated, then paralyzed; please see the nursing record for drugs and dosages administered.  The vocal cords were visualized, and the endotracheal tube was inserted without complication.  Tracheal position was confirmed using auscultation, capnometry, tube condensation, and chest x-ray.  The tube was appropriately secured.  Appropriate analgesia, and/or sedation was provided for patient comfort.

 

 

PROCEDURE:  REMOVAL OF FOREIGN BODY FROM EYE

 

I initially preformed a general eye exam, as well as a slit lamp examination. It was determined that the patient had a foreign body in their eye.  First I anesthetized there light with Alcaine eye drops. Then utilizing a slit lamp I then proceeded to use a sterile 18-gauge needle to free up the foreign body. With a sterile Q-tip, I was easily able to remove the foreign body.  There was no penetration of the globe.

 

There is a slight amount of residual rust ring. I was able to remove most of this as well.  I utilized an OPHTHALMIC BURR to help facilitate doing this.

 

Patient tolerated the procedure well, and was given multiple verbal instructions by myself about how to take care of their  condition over the next few days.  I recommended a repeat eye evaluation in 24-48 hours either with their ophthalmologist or back here in this ED.  Obviously they were told to return immediately if any worsening vision, increasing pain, or any other concerns.

 

PROCEDURE:           _____  FINGER CLOSED REDUCTION

 

By applying gentle longitudinal traction, I was able to reduce the dislocated finger without much difficulty. Clinically the patient's function was markedly improved. There distal cap refill was less than 2 seconds.   And the previous aforementioned dislocation, clinically appear to be resolved.  The patient tolerated the procedure well, and was placed in an AlumaFoam splint. Recommended follow up as we discussed, and return if any issues.

 

PROCEDURE:     Hematoma block  -   LEFT distal radius

 

              Because of this patient's pain at the site of the fracture. I performed a local hematoma block to help alleviate the pain and allow for the possibility of closed reduction of this patient's fracture.

 

              Before doing this procedure, I did check the patient's distal neurovascular status. There is some mild decreased range of motion which I attributed to the pain but no evidence of obvious vascular or neurological compromise.

 

              Then, I identified the appropriate landmarks, and I sterilely prepped the skin at the insertion site.   Using plain Sensorcaine, I inserted the needle [and withdrew to make sure I was not in a blood vessel], then I slowly injected approximately 4 or 5 mls in the region of the fracture site.     The patient appeared to tolerate the procedure well and her pain was improved.   Repeat evaluation of the distal extremity revealed no change or compromise in the vascular integrity.

 

 

PROCEDURE:  HVLA in the thoracic area.

 

On my examination, this patient had a thoracic lesion with rotation. The patient was placed in the supine position with arms folded in front of the chest. I then placed the thenar eminence of my palm over the most prominent area of the lesion at the costovertebral junction. Then using a high velocity low amplitude technique, I then reduced the somatic dysfunction. The patient tolerated this procedure well.

 

PROCEDURE INFRAORBITAL BLOCK:

 

            In order to anesthetize the patient's mid-face region, I performed an infra-orbital nerve block to provide regional anesthesia. I injected approximately 3 mls of Sensorcaine with epinephrine into the area where the inferior orbital nerve comes out. Patient had good anesthetic effect in that region.

 

PROCEDURE INTRAOSSEOUS LINE:   tibia

 

                Because this patient had no intravenous access I immediately placed a  LEFT  proximal tibial intraosseous (IO) line.   The area was identified and then prepped with Betadine in a sterile fashion.   Then using the EZ-IO drill, I was able to easily insert a 15-gauge needle into the bone marrow of the proximal tibia.   I was able to withdraw bloody bone marrow and was able to flush the area without any difficulty or extravasation.   This was then connected to a hep well for fluid and medication administration, in order to resuscitate the patient.   

 

PROCEDURE INTRAOSSEOUS LINE:   shoulder

 

                Because this patient had no intravenous access I immediately placed a  RIGHT  proximal humerus intraosseous (IO) line.   The area was identified and then prepped with Betadine in a sterile fashion.   Then using the EZ-IO drill, I was able to easily insert a 15-gauge needle into the bone marrow of the proximal humerus.   I was able to withdraw bloody bone marrow and was able to flush the area without any difficulty or extravasation.   This was then connected to a hep well for fluid and medication administration, in order to resuscitate the patient.   

 

PROCEDURE:     ASPIRATION OF THE  LEFT  KNEE:

 

             The indication was to rule-out septic arthritis of the knee, as well as to further evaluate for the cause of the patient's effusion.  The risks and the benefits were discussed with the patient, and verbal consent was given to proceed.

 

            Prior to the procedure, I placed 4% topical LIDOCAINE on the LATERAL aspect of the knee, over the most prominent part of the effusion.

 

           Once the skin was anesthetized, the skin area was sterilized with Betadine.  Then using a sterile 18g needle, and sterile technique, I then inserted the needle, withdrawing on the syringe plunger.

 

           _____  mls of yellowish synovial fluid was obtained.  This was sent down to the lab for joint analysis, as well as for culture.  A dressing was placed, and the patient tolerated the procedure well.   Instructions were given to the patient, regarding the arthrocentesis.

 

PROCEDURE:   laceration of FINGER, with INTERMEDIATE SIMPLE repair.                Total length = _ cm.

 

After evaluation, I decided that this patient's laceration needed to be repaired.

I first anesthetized the laceration with 0.5% Sensorcaine PLAIN.

Then the wound was cleansed and irrigated with normal saline solution. Sterile drapes were placed to maintain a sterile field.

 

Utilizing sterile technique, I then evaluated and explored the wound for any abnormalities, such as foreign body, infection, tendon, nerve, or joint involvement.

Seeing none, I then proceeded to repair the laceration.

Utilizing a 4.0 Ethilon suture, and then placed a total of  __  sutures.

The patient tolerated the procedure well.

 

They then had a Neosporin dressing applied to the wound.

The patient was informed to have a wound check in about 2 days, and sutures cut out in about 10-12 days.

They are to return at any point if they have any concerns including infection or any other issues.

 

 

PROCEDURE:    Laceration of  ______ .     with INTERMEDIATE SIMPLE repair.  Total length = ___ cm.

 

After evaluation, I decided that this patient's laceration needed to be repaired.

I first anesthetized the laceration with 0.5% Sensorcaine with epinephrine.

Then the wound was cleansed and irrigated with normal saline solution. Sterile drapes were placed to maintain a sterile field.

Utilizing sterile technique, I then evaluated and explored the wound for any abnormalities, such as foreign body, infection, her vital tissue involvement.

Seeing none, I then proceeded to repair the laceration.

Utilizing a 4.0 Ethilon suture, and then placed a total of ____ sutures.

The patient tolerated the procedure well.

They then had a Neosporin dressing applied to the wound.

The patient was informed to have a wound check in about 2 days, and to return at any point if they have any concerns including infection or any other issues.

 

 

PROCEDURE:   LACERATION SCALP

 

This patient suffered a scalp laceration that required repair. After evaluating the area, I then prepped the area as best as I could. Any hairs around the wall and were clipped after obtaining permission to do this. There was also cleansed with Betadine as best as could be done. Trying to maintain a sterile field, the bullet was then cleansed and further explored under sterile conditions. No evidence of skull fracture, or galea involvement. No evidence of retained foreign body or other significant abnormalities.

 

Using a sterile suture gun, a total of   _____  staples were placed to approximate the wound edges. Neosporin was applied to the wound. Patient tolerated the procedure well.  I recommended a wound check in a couple days, and that the staples come out in about 7 days.

 

PROCEDURE:     Laceration of TOE NAIL matrix, with complex  repair.                Total length = 1 cm.

 

             After evaluation, I decided that this patient's laceration needed to be repaired.    I first anesthetized the digit with 0.5% Sensorcaine PLAIN.  Then the wound was cleansed and irrigated with normal saline solution.   Sterile drapes were placed to maintain a sterile field.

 

Utilizing sterile technique, I then evaluated and explored the wound for any abnormalities, such as foreign body, infection, tendon, nerve, or joint involvement.    The toenail was almost entirely already avulsed, thus, I facilitated its complete removal, utilizing iris scissors.   Then I thoroughly washed and irrigated the digit as well as the nail matrix.    Utilizing a 4.0 Vicryl suture I placed a total of  4  simple interrupted sutures to best approximate the laceration in the nail matrix.    After which I then repaired the toenail and thoroughly cleansed and irrigated and trimmed up the edges.  I then replaced it back into its normal area, and secured it with Dermabond, followed by a sterile dressing.

 

The patient tolerated the procedure well.

The patient was informed to have a wound check in about 2 days.   I gave him some verbal instructions about the Dermabond and that it would fall off in the next 5-10 days.    I also explained that the Vicryl sutures underneath the toenail are absorbable and will not need to be cut out.    At any point they are to return back to our ED for reevaluation including increasing pain, redness, or any signs of infection.   Finally, I explained that there is a definite possibility that a new toenail may not ever come out.    Or if one does, it may be deformed.    

They are to return at any point if they have any concerns including infection or any other issues.

 

Procedure:      Lumbar Puncture.

 

The procedure was explained to the patient/surrogate with an opportunity to ask questions, and the risks, benefits, and alternatives were discussed.  The potential complications, including post-LP headache, localized pain (during, and afterwards), infection (epidural abscess, discitis, etc), and bleeding (hematoma) were also discussed.  Informed consent was obtained.

 

Prior to the procedure, a "time-out" was performed.

The patient was placed in a seated position, leaning forward over a table.   The L2-L3 interspace was identified and marked. 

 

Sterile gloves, sterile gown, and masks were put on.  Then, the lumbar region was prepped and draped to maintain a sterile field.  A local anesthetic was used to anesthetize the tissues surrounding and including the interspace.  A 22 gauge spinal needle was inserted through the interspace and approximately 4mL of CSF was collected, and sent to the lab for analysis. The patient tolerated the procedure well, and there were no identifiable complications during the procedure.

 

If obtained, the opening pressure was documented in the patient’s chart.

 

 

 PROCEDURE:  INCISION AND DRAINAGE  

 

Patient had an abscess of the    _______ .

The local area was first anesthetized using Sensorcaine.

Then the area was prepped in a sterile fashion, and utilizing a #11 blade scalpel, I made a surgical incision over the most fluctuant area. 

I then expressed any pus that I could from the area, followed by irrigation.

Then I used a 1/4 inch iodoform packing to pack the wound gently.

The patient tolerated the procedure well, and a dressing was placed. 

The patient was informed that the packing should be removed in about 2 or 3 days.   They may follow up with their PCP to have this done, or may return to our ED for re-evaluation, and packing removal. 

In addition, the patient was also given other verbal instructions by myself, regarding how to care for this, the contagiousness, etc.     As we discussed, they may return at any point, if they believe that their condition is worsening in any way.

 

PROCEDURE:  nursemaid's elbow:  LEFT

 

This patient appeared to clinically have a nursemaid's elbow. No evidence of distal vascular injury and no evidence of obvious displaced fracture. After describing to the parents the procedure, I then had the child held on a lap while facing me.  The affected extremity was left free for me to manipulate. I placed pressure over the proximal radial head, and then proceeded with a flexion and extension maneuver in his slow fashion. The child obviously cried during this procedure but she was thereafter appeared to be fine. A few minutes later the child was observed to be moving the arm in a normal fashion. They were discharged in stable condition and instructed not to pull on the arm longitudinally in the future. Return if any questions or concerns.

 

PROCEDURE:     OCCIPITAL NERVE BLOCK

 

               Patient underwent an occipital nerve block for pain relief of his scalp. The area at the base of the skull posteriorly was identified and cleansed. Then utilizing 0.5% Sensorcaine with epinephrine, I then injected about 3 mls at the base of the occipital nerve. Patient tolerated the procedure well and had significant improvement of the pain in the distribution of that occipital nerve.

 

PROCEDURE PARONYCHIA:             This patient has a paronychia of the   _____ .

 

After the area was anesthetized, I then prepped this area with Betadine solution. Then was prepped in a sterile fashion. Utilizing iris scissors, I then opened up the area of pus and tried to express any pus that was in that area. There is no evidence of felon, septic arthritis, or obvious retained foreign body.

 

I then cleaned out the area as best I could, and then a dressing was placed. The patient tolerated the procedure well. They were given verbal instructions by myself to keep the area clean, and to continue a Neosporin and Band-Aid for couple days and to return immediately if the condition worsens as we discussed.

 

PROCEDURE:   PercuVision

 

             It was determined that this gentleman has a difficult ureter for trying to insert a Foley catheter.   For this reason, it was determined to use the fiberoptic device to help facilitate passage of a catheter into this patient's bladder.   The patient was informed of the need for this procedure and was in agreement having it done.

 

             The PercuVision monitor was placed in the room and set up in usual fashion, including white balancing and focusing.   The patient had a Urojet injected into the penile opening to help lubricate and anesthetize his ureter.  Then the fiberoptic port was primed with sterile saline.  I then carefully placed the guide into the catheter port making sure not to kink it.   Then, with my assistant's help, the irrigation was then connected to the center port, & the fiberoptic light source was also hooked up, and turned on. 

 

              The penis was prepped in sterile fashion using Betadine, followed by a sterile drape.    I then slowly entered the fiberoptic scope [with the catheter] into his penis, & then had the irrigation turned on.   I slowly advance the guide and manipulated it, as well as his penis to help facilitate passage into the bladder.  Once inside the bladder, I then carefully removed the fiberoptic guide, and placed the cap over that port.  The irrigation was turned off.   I then advanced the catheter almost all the way to the hub, & used 10 mls of sterile water to inflate the catheter balloon inside the bladder.   The middle port was disconnected from the irrigation, and the Foley bag was connected.   Urine flowed from the patient's bladder into the collection bag.  The patient's symptoms were significantly improved and he tolerated the procedure well.

 

 

PROCEDURE:      Incision and drainage of a pilonidal abscess

 

Then the area was prepped in a sterile fashion.

The local area was first anesthetized using Sensorcaine.

Then, utilizing a #11 blade scalpel, I made a surgical incision over the most fluctuant area. 

I expressed any pus that I could from the area, followed by copious irrigation.

A 1/4 inch iodoform packing was packed in the surgical incision.

The patient tolerated the procedure well, and a dressing was placed.

The patient was informed that the packing should come out in about 2 or 3 days, and was given written and verbal instructions.

 

 

 

PROCEDURE:     PROCEDURAL SEDATION

 

The risks and benefits of procedural sedation, as well as other alternatives were explained to the patient and/or guardian.  The reason was to alleviate the patient's pain during the procedure.  Some of the potential adverse reactions discussed were apnea ("stop breathing"), allergic reaction, vomiting, hypotension, and even possibly death.  Other possible alternatives were discussed and then informed consent was then obtained.  

 

The patient was made NPO, and has not recently had any large meals.

The patient was placed on a monitor as well as end-tidal CO2 monitor, as well as oxygen via nasal cannula. The vital signs are stable prior to the procedure.  Prior to the start of the procedure the nurse and I performed a TIME OUT.  We made sure all the necessary equipment, including crash cart, defibrillator, airway box, and suction were readily available.

 

Once we were agreeable to proceeding, I then gave the patient 40 mg of IV KETAMINE.

 

I continued to closely watch the patient's pulse oximeter, end-tidal CO2 monitor, vital signs, and cardiac monitor for any abnormalities. The patient appeared to have adequate sedation and underwent the procedure well.  After which, the patient was observed, to ensure that the patient woke up fully, and was back to baseline.  The intra-service time for this procedure was 16 minutes.

 

Procedure:         RSI  (Rapid Sequence Intubation)

 

Because of the patient's severe respiratory distress, and/or other factors, we proceeded with emergent rapid sequence intubation.

We prepared by pre-oxygenating the patient, and checking the equipment such as the laryngoscope, ETTs, and suction. The crash cart and difficult airway box, were also readily available.

The patient was maintained on a cardiac monitor, end-tidal CO2 monitor, oxygen, continuous pulse oximetry, and IV fluids were running.

 

The patient was then induced using IV   ETOMIDATE.

This was followed immediately by SUCCINYLCHOLINE, while maintaining gentle cricoid pressure.

Once paralyzed, the vocal cords were visualized utilizing a Mac Blade.  Then a 7.5 endotracheal tube was placed using direct laryngoscopy. The cuff was inflated, and the tube was secured by the respiratory therapist.  Tube placement was confirmed via auscultation, capnometry, condensation in the tube, and finally by portable CXR.

 

The patient was then stabilized on a ventilator.  Shortly thereafter, an ABG was obtained and analyzed.

Subsequent to this, the patient was given adequate analgesia using a FENTYNAL DRIP, as well as other prn meds to make sure the patient was comfortable

Although critical, the patient did survive the RSI procedure without significant complications.

 

PROCEDURE   -   shoulder reduction:   RIGHT

 

This patient underwent a shoulder reduction. Utilizing procedural sedation, I made the patient comfortable and then used gentle traction as well as abduction of the upper arm, which then allow the shoulder to easily reduced back into place. After the procedure the distal neurocirculatory status remained intact.  The patient was placed in a sling for comfort.

 

There is no evidence of significant fracture or dislocation post procedure.  Patient was given instructions about keeping the elbow by the side. The patient will need to start doing range of motion exercises and physical therapy as dictated either by their primary care physician or their orthopedist.

 

PROCEDURE:    SLIT LAMP EXAMINATION

 

This patient underwent a slit lamp examination performed by myself.   The affected eye(s) was initially inspected with direct vision. I then anesthetized with Alcaine drops, followed by fluorescein dye.   I evaluated the entire eye and also everted the upper eyelid checking for any foreign bodies.

 

I then used the slit lamp to thoroughly evaluate all areas of the patient's affected eye. The results of my examination did not reveal any globe penetration, nor dendrites, nor was there any retained foreign body or corneal ulcerations.

 

 

PROCEDURE:  SPLINTER REMOVAL                                                                  

 

           After the area was anesthetized, I prepped the area with betadyne, and then with a sterile drape.  Then utilizing a #11 blade scalpel I carefully dissected down to where the FB was located.  Then, using curved hemostats, I was then able to easily remove the FB in its entirety.  The rest of the wound, and wound base were explored, and no other obvious FBs could be appreciated.  I then copiously irrigated the wound, and had the staff cover with a dressing.  The patient tolerated the procedure well.  

           I did explain the concern for infection, and to return to our ED immediately should they have any concerns.  I also explained that sometimes FBs can remain, and cannot always be visualized.  Finally, I recommended a wound check in about 2-3 days (or sooner, if any worsening).

 

PROCEDURE SUBUNGUAL HEMATOMA -DRAINAGE:        right   index   finger

 

This patient underwent drainage of their subungual hematoma since there was more than 33% of the nail surface involved, and they are having significant pain and pressure. This was done utilizing an electric cautery; that was placed in the most central area. Dark venous blood oozed from the hole.  A Neosporin dressing was placed by the nursing staff.  The patient tolerated the procedure well. 

 

PROCEDURE:    Drainage of  THROMBOSED HEMORRHOID.

 

The patient was placed in a lateral recumbent position. The buttock cheeks were separated and the area was visualized with light. It was cleansed as best as I could.

 

Then utilizing 0.5% Sensorcaine with epinephrine, I then injected a couple mls at the base of the thrombosed hemorrhoid as well as the top of it.

 

Then utilizing a sterile #11 blade scalpel, I then made a surgical incision over the most prominent part of the thrombosed hemorrhoid. I then expressed a thrombosis from the vein. Bleeding was minimal. Dressing was placed. Patient tolerated the procedure well.

 

I discussed treatment specific to this patient, as well as keeping the area clean several times a day using a sitz bath. I also informed them that they may require definitive surgical treatment in the future. However if they've any concerns or problems they are to return back to this emergency department as we discussed.

 

 

PROCEDURE:    ultrasound, billable

________   US study was personally performed and interpreted by myself, and the US images were stored electronically.  My findings revealed _________

 

PROCEDURE:    ultrasound, non-billable

A quick look, non-billable ultrasound shows the following:  _____________

 

PROCEDURE:    ultrasound, teaching

An educational, non-billable bedside ultrasound was performed.  No medical decisions were made from this study, and the patient was informed of this.