Common Office Procedures
Baby Health Service
Lexington, KY
Spalding University
Louisville, KY
Delwin B. Jacoby, DNP, APRN
Delwin B. Jacoby, MSN, APRN
has no financial interest or
affiliations with any entities
regarding this content – April
17, 2013
Objectives for Common Office Procedures
Review AHA recommendations for antibiotic prophylaxis
for common office procedures.
Demonstrate removal procedures for veruccae and
acrochordons.
Discuss management of subungual hematomas.
Develop a plan for the management of ingrown toenails.
Demonstrate correct procedure for a digital nerve block
in both hands and feet.
Perform incision and drainage of an uncomplicated
abscess and paronychia.
Demonstrate procedures to biopsy suspicious lesions–
shave biopsy, punch biopsy, and elliptical excision.
Overview of Simple Office
Procedures
 Can be performed in most any office
 Requires the following:
 good light source
 exam table
 mayo stand/table
 basic instruments and equipment
 protective gear
 anesthesia
 suture material
Basic Instruments & Equipment
Scalpels, scissors, punches
Forceps
Undermining scissors
Hemostats
Needle holders
Syringes and needles
Cotton swabs
Liquid nitrogen/cryo
Gauze pads
Suture material
English Nail Anvil *
Universal
Precautions
&
Sterile Technique
Antibiotic Prophylaxis
April 2007 - New AHA guidelines for antibiotic
prophylaxis
– Prosthetic cardiac valve
– Previous infective endocarditis
– Congenital heart disease only in the following categories:
Unrepaired cyanotic congenital heart disease,
including those with palliative shunts and conduits
Completely repaired congenital heart disease with prosthetic
material or device, whether placed by surgery or catheter
intervention, during the first six months after the procedure*
Repaired congenital heart disease with residual defects at the
site or adjacent to the site of a prosthetic patch or prosthetic
device (which inhibit endothelialization)
– Cardiac transplantation recipients with cardiac valvular disease
Acrochordons (Skin Tags)
• Commonly found on neck,
axilla, bra-line, groin
• Topical Anesthesia +/• EMLA
• Cetacaine spray
• Grasp tag with forceps and
snip base with sharp scissors
• Apply pressure for hemostasis
and dress
• Review S & S of infection
• No follow-up needed
• Few complications
Acrochordons (Skin Tags)
CPT - 11200 - Removal any method of up to 15 tags any area
CPT – 11201 – Removal of each additional 10 lesions.
Warts
Common, generally
benign condition of viral
etiology
Challenging!!!!
Commonly spread by
auto-inoculation
Cosmetically unappealing
Often resolve
spontaneously
Tend to be recurrent no
matter the treatment
option
Occur most commonly in
children
Types of Warts (Verrucae)
Verruca vulgaris – common warts
Periungual warts – occur around nails
Verruca planus – flat warts
Verruca plantaris – plantar warts
Condylomata acuminata
Warts
Epidermal overgrowths caused by HPV. Spread
by direct contact.
HPV type 1,2,4 – Assoc with Plantar Warts
(verruca plantaris)
HPV type 3 &10 – assoc with Flat Warts
(verruca planus)
HPV type 16,18,31 assoc with genital warts –
assoc with genital cancers (condylomata
accuminata).
HPV 2,4,7,27,29 – Assoc with common warts
(verruca vulgaris)
Verrucae
Common Treatments for Warts
Chemical Destruction
– Salicylic Acid
– Podophyllin/Podophylloxin
– Trichloracetic acid
– Bichloracetic acid
– Others
Immune system modulator –
Imiquimod (Aldara)
Cryotherapy
– Liquid nitrogen
Duct Tape?!?!
Cryotherapy
Application of extreme cold to destroy lesions
Easy to use
Quick
Generally good results with little scarring
No local anesthesia needed/pain tolerable
Multiple lesions can be treated
Cryotherapy - Disadvantages
Initial cost and set-up
Postoperative pain
Lesion recurrence
Hypopigmentation may occur
Repeat visits common
Occasional scarring
Cryotherapy - Precautions
Previous Rx to cryotherapy
Do not use on suspected cancerous lesions
Caution around nails and nailbed
Do not use on eyelids, elbow, digits - relative
contraindication
Nose, ears, lips, ant. tibial area - caution
Dark skin
Vascular compromise
Immunocompromised patients
Cryosurgical Systems
Liquid nitrogen - 196 degrees C
Verruca-Freeze (chemical refrigerant) - 70
degrees C
Histofreezer (chemical refrigerant) - 55
degrees C
Cryosurgery
Cryosurgical Products
Cryosurgery
Techniques
CPT - 17000 –
Destruction benign or
premalignant lesion by
any method, first lesion.
CPT – 17003 - Destruction
benign or premalignant
lesion by any method, 2nd
– 14th lesion.
Cryotherapy - Veruccae
Nail Anatomy
Subungual Hematoma
Painful accumulation of
blood under the nail
secondary to trauma
Evacuation relieves pain
> 50% of nail bed
involvement suggests sig.
laceration and possible
fracture.
Assess neurovascular
function prior to
procedure
Patient education and
expectations are very
important
Subungual Hematoma Evacuation
CPT – 11740 –Evacuation of subungual hematoma
Ingrown Toenail (Onychocryptosis)
Common
Leads to pain/
disability
Etiology - ill-fitting
shoes, improper
toenail cutting, trauma.
Ingrown toenail
spicule leads to
inflammatory response
Stages of Ingrown Toenails
Stage 1 - erythema, pain,
swelling
Stage II – erythema, pain,
swelling, suppuration
Stage III – granulation
tissue, hypertrophy along
with stage II
characteristics
Ingrown Toenail (Onychocryptosis)
Ingrown Toenail Management
Stage 1 – Conservative management
Stage 2 – Partial toenail removal
Stage 3 – Partial toenail removal;
Consider referral to Podiatrist
Partial Nail Removal
Soak in warm H20 prior to procedure
Digital nerve block bilaterally with plain
2% xylocaine or bupivacaine (marcaine)
0.25%
Prep area with betadine
Elevate the nail edge with hemostats or
nail elevator
Partial nail removal 2-3 mm with nail
splitter or sharp scissors
Partial Nail Removal (Cont.)
Remove the wedged section by rotating
the separated portion toward the healthy
nail
Apply phenol solution (88%) to the nail
matrix
Apply topical antibiotic and dressing
Dispense wound care instructions
Recheck as needed, observe for signs of
infection
Prevention instructions
Ingrown Toenail - Partial Nail
Removal
English Nail Anvil
Ingrown Toenail - Partial Nail
Removal
CPT – 11730 – Avulsion of nail plate, partial or complete, simple; single
Digital Nerve Block
Digital
Nerve Block
***No CPT exists for digital
nerve block; Service included
in procedure performed.
Abscess
Incision and Drainage of Abscess
Abscess – local collection of purulent materiel
in a cavity surrounded by inflamed tissue.
– produces pain, pressure and tissue damage.
Furuncle (boil) – Starts in hair follicle or sweat
gland
Carbuncle – furuncle extends to subcutaneous
tissue
Acute paronychia – abscess around nail
Bacteria involved – Mostly S. aureus and other
gram+ organisms, MRSA common !!
Skin Tension Lines
Indications for I & D of Abscess
An abscess must be drained in order to
heal
Systemic antibiotics cannot penetrate the
abscess
Check to see if the lesion is “fluctuant”
All skin abscesses, furuncle/carbuncle,
inflamed epithelial cysts, paronychia with
abscess must have I & D for resolution
Contraindications/Caution
Facial abscess - CN VII
Caution in area around vital
structures such as the eye and neck
Caution in areas overlying nerves and
blood vessels
Instruments Needed
Surgical Blades
I & D Procedure
Determine skin tension lines to minimize
scarring
Prep skin with antibacterial agent
Inject local anesthesia
Make a 90 degree stab incision with #11 scalpel
blade
Apply pressure to expel purulent material
If no purulent material, reassess and try again
Break up loculations with swab, hemostat or
curette
+/- Pack with nu-gauze *
Apply dressing
I&D
Procedure
CPT – 10060 - I & D of single
or simple abscess
I & D Follow-up/Patient Education
Quick shower and change outer dressing
Expect additional drainage
Return visit 1-2 days
Management options at revisit
– Remove packing and repack
– Remove packing completely
– Partially remove packing
Follow-up as needed for resolution
Warm H2O soaks?
Complete healing takes 7-21 days or longer
Fingernail/Toenail Paronychia
Infection of the nail fold.
Usually S. aureus if acute; may be Candida
albicans if chronic (>6 weeks).
Toenail paronychia often associated with
ingrown toenail and requires partial toenail
removal.
Usually no anesthetic needed. May use ethyl
chloride as local anesthesia
Insert #11 blade into area of fluctuance
Apply pressure and drain
Warm H20 soaks until resolved
Draining Paronychia
CPT – 10060 – I & D of single or simple abscess
Punch Biopsy
Fast and easy procedure to obtain a full
thickness specimen for pathology.
Indicated for unknown and malignant
lesions.
Great for diagnostic purposes for flat
lesions.
Useful to remove small, flat nevi.
Usually good cosmetic results
Useful to diagnose inflammatory disease
Indications for Punch Biopsy
Diagnosis
– Inflammatory
skin disease
– Skin cancer
Removal
– Small nevi
– Dermatofibromas challenging/often
better to not remove
Contraindications of Punch Biopsy
Less than optimal biopsy technique for
SCC and BCC
Must Know Anatomy!!!!!!!!!!!!!!
– Facial nerve
– Trigeminal nerve
– Eyelid
– Digits
– Areas with little soft tissue – tibia, digits, ulna,
etc
Equipment for Punch Biopsy
Punch – 2-8mm. Choose the punch that can
completely excise the lesion
– < 3mm may not need sutures
– > 6mm , best to use an elliptical excision.
Fine, sharp-sharp scissors
Forceps
Needle holder
Suture material
Local anesthesia
Punch Biopsy Procedure
Sterile Technique
Choose a punch to remove entire lesion
Local anesthesia 1% lidocaine
Apply tension perpendicular to Kraissel’s lines
with hand not performing the punch.
Apply punch completely over the lesion, apply
pressure, and rotate through the dermis –
expose the subq. Adipose tissue.
Remove the plug, cut with sharp-sharp scissors
and send for pathology
Undermine if needed
Close with simple interrupted sutures
Dress and provide follow-up instructions
Punch Biopsy
CPT – 11100 – Biopsy of skin,
subcutaneous
CPT – 11101 – Biopsy of each
separate or additional lesion.
Shave Biopsy
Indicated for raised
lesion removal
Advantages – minimal
time, simple, no
suturing, generally
good cosmetic results
Shave Biopsy
Consider for
–
–
–
–
skin tags
seborrheic keratosis
nevi
actinic keratosis
Not indicated for
suspected melanoma!!
Shave Biopsy
Prep skin
Local anesthesia to elevate lesion
Use #15 blade or DermaBlade
Excise the lesion level or minimally depressed in
relation to the surrounding skin.
Achieve hemostasis
– Pressure
– Electrodessication
– Topical agents
Aluminum chloride
Monsel’s solution
Silver nitrate
Submit for pathology
Shave Biopsy
Shave Biopsy - DermaBlade
CPT – Depends on site and size.
11300 – Trunk, arm, leg < 0.6 cm
11301 - Trunk, arm, leg 0.6 – 1.0
cm
Many others, see CPT code book.
Elliptical Excision
Used when lesion is too large for punch
Removes full thickness lesion
Major steps
– Planning
– Anesthesia
– Incision
– Undermining
– Hemostasis
– Closure
Planning the Elliptical Excision
Avoid vital structures! Know anatomy!
Know Kraissel’s lines and plan accordingly
Incisional margin 3x diameter of lesion
Anesthesia
Incision with # 15 blade perpendicular to
the skin surface through epidermis and
dermis
Undermine to allow closure of the incised
area
Surgical Blades
Elliptical Excision
Hemostasis – pressure, electrocautery,
local anesthesia with epinephrine if
indicated!!!!
Wound closure – vertical mattress, 2 layer
closure, single layer closure.
Send specimen for pathology
Elliptical Excision
Remember………… Skin tension lines!!!!
Elliptical
Excision
Elliptical
Excision
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 Procedures
References
American Heart Association (2007, April 19). Prevention of
Infective Endocarditis: Guidelines From the American
Heart Association, by the Committee on Rheumatic
Fever, Endocarditis, and Kawasaki Disease. Circulation
Buttaravoli, P (2012) Minor Emergencies. Splinters to
Fractures, 3rd Edit. Mosby
Blair, RE (2007, March) “Surgical Management of Soft
Tissue MRSA Abscesses”, Family Physician News
Mayeaux, EJ (2009)The Essential Guide to Primary Care
Procedures. Wolters/Lippincott/Williams &Wilkins
Pfenninger, JL (2011) Procedures for Primary Care, 3rd
Edition: Mosby
Trott, AT (2012) Wounds and Lacerations, 4th Edit. Mosby