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Atlas of Primary Care Procedures (1st Ed.)
Atlas of Primary Care Procedures (1st Ed.)
[+] Editors
- PREFACE
- ACKNOWLEDGMENTS
TABLE OF CONTENTS
[-] General Procedures
[+] 1 - Incision and Drainage of Abscesses
[+] 2 - Lumbar Puncture
[+] 3 - Thoracentesis
[+] 4 - Chest Tube Insertion
[+] 5 - Abdominal Paracentesis
[+] 6 - Ring Removal
[+] 7 - Fishhook Removal
[+] 8 - Tick Removal
[-] Dermatology
[+] 9 - Local Anesthesia Administration
[+] 10 - Punch Biopsy of the Skin
[+] 11 - Shave Biopsy
[+] 12 - Fusiform Excision
[+] 13 - Skin Tag Removal
[+] 14 - Simple, Interrupted Skin Suture Placement
[+] 15 - Running Cutaneous and Intracutaneous Sutures
[+] 16 - Vertical Mattress Suture Placement
[+] 17 - Horizontal Mattress Suture Placement
[+] 18 - Minimal Excision Technique for Removing Epidermal Cysts
[+] 19 - Skin Cryosurgery
[+] 20 - Dermal Radiosurgical Feathering and Ablation
[+] 21 - Scalp Repair Techniques
[+] 22 - Tangential Laceration Repair
[+] 23 - Field Block Anesthesia
[+] 24 - Lipoma Removal
[+] 25 - Basic Z-Plasty
[+] 26 - Advancement Flap Placement
[+] 27 - O-To-Z Plasty
[+] 28 - Sclerotherapy
[-] Nail Procedures
[+] 29 - Digital Nerve Block
[+] 30 - Ingrown Nail Surgery
[+] 31 - Subungual Hematoma Drainage
[+] 32 - Nail Bed Biopsy
[+] 33 - Paronychia Surgery
[+] 34 - Digital Mucous Cyst Removal
[-] Gynecology and Urology
[+] 35 - Endometrial Biopsy
[+] 36 - Cervical Polyp Removal
[+] 37 - Colposcopy and Directed Cervical Biopsy
[+] 38 - Cryotherapy for the Uterine Cervix
[+] 39 - Loop Electrosurgical Excisional Procedure
[+] 40 - Treatment of Bartholin's Gland Cysts and Abscesses
[+] 41 - Treatment of Noncervical Human Papillomavirus Genital Infections
[+] 42 - Fine-Needle Aspiration of the Breast
[+] 43 - Fitting Contraceptive Diaphragms
[+] 44 - Intrauterine Device Insertion and Removal
[+] 45 - Gomco Clamp Circumcision
[+] 46 - No-Scalpel Vasectomy
[-] Gastroenterology
[+] 47 - Anoscopy with Biopsy
[+] 48 - Flexible Sigmoidoscopy
[+] 49 - Esophagogastroduodenoscopy
[+] 50 - Colonoscopy
[+] 51 - Excision of Thrombosed External Hemorrhoids
[+] 52 - Treatment of Internal Hemorrhoids
[-] Ear, Nose, and Throat Procedures
[+] 53 - Conjunctival and Corneal Foreign Body Removal
[+] 54 - Chalazia Removal
[+] 55 - Treatment for Anterior Epistaxis
[+] 56 - Flexible Nasolaryngoscopy
[+] 57 - Cerumen Impaction Removal
[+] 58 - Foreign Body Removal from the Auditory Canal and Nasal Cavity
Because this is a new code for 2003, there is no 2002 fee available.
CPT is a trademark of the American Medical Association.
INSTRUMENT AND MATERIALS ORDERING
Consult the ordering information that appears in Chapter 65. Ganglion cysts are best aspirated with 16- or 18-gauge, 1-inch needles. A
hemostat may be used to exchange the injection syringe for the aspiration syringe. Needles, syringes, and ace wraps may be ordered from
local surgical supply houses. Hemostats may be ordered from instrument dealers. The only U.S. manufacturer of hyaluronidase has been
Wyeth, but Wyeth discontinued production of hyaluronidase in 2002. A suggested tray for performing soft tissue aspirations and injections
is listed in Appendix D. Skin preparation recommendations appear in Appendix H.
BIBLIOGRAPHY
Beetham WP, Polley HF, Slocumb CH, et al. Physical examination of the joints. Philadelphia: WB Saunders, 1965:5657.
Buttaravoli P, Stair T. Minor emergencies: splinters to fractures. St. Louis: Mosby, 2000:290291.
Ho PC, Griffiths J, Lo WN, et al. Current treatment of ganglion of the wrist. Hand Surg 2001;6:4958.
Jones JG. Selected disorders of the musculoskeletal system. In: Taylor RB, ed. Family medicine principles and practice,5th ed. New
York: Springer, 1998:10051015.
Klippel JH, Weyand CM, Wortmann RL. Primer on the rheumatic diseases, 11th ed. Atlanta: Arthritis Foundation, 1997:141.
Leversee JH. Aspiration of joints and soft tissue injections. Prim Care 1986;13:579599.
Mercier LR, Pettid FJ, Tamisiea DF, et al. Practical orthopedics, 4th ed. St. Louis: Mosby, 1991:104105.
Osterman AL, Raphael J. Arthroscopic resection of dorsal ganglion of the wrist. Hand Clin 1995;11:712.
Owen DS, Irby R. Intra-articular and soft-tissue aspiration and injection. Clin Rheumatol Pract 1986;Mar-May:5263.
Paul AS, Sochart DH. Improving the results of ganglion aspiration by the use of hyaluronidase. J Hand Surg Br 1997;22:219221.
Wang AA, Hutchinson DT. Longitudinal observation of pediatric hand and wrist ganglia. J Hand Surg Am 2001;26:599602.
Wilson FC, Lin PP. General orthopedics. New York: McGraw-Hill, 1997:424425.
P.587
Editors: Zuber, Thomas J.; Mayeaux, E. J.
Title: Atlas of Primary Care Procedures, 1st Edition
Copyright 2004 Lippincott Williams & Wilkins
> Back of Book > Resources > Appendices
Appendices
Appendix A: Instruments and Materials in the Office Surgery Tray
The following instruments and materials are included in the suggested office surgery tray:
No. 15 scalpel blade
Scalpel blade handle
Webster needle holder
Metzenbaum tissue scissors
Straight iris scissors
Adson forceps with teeth
Adson forceps without teeth
2 mosquito hemostats
2 inches of 4 4 gauze
Fenestrated disposable drape
21-gauge, 1-inch needle (bent into a skin hook)
These materials are dropped onto a sterile disposable drape laid across a metal stand. Anesthetic is applied with nonsterile gloves and a
syringe not placed on the tray. Sterile gloves are then applied away from this sterile tray. Added to the tray are sterile suture materials
(e.g., 4-0 nylon suture) that are required for the particular procedure.
Gloves, materials, and instruments can be ordered from the following sources:
Delasco, Council Bluffs, IA (http://www.delasco.com)
Robbins Instruments, Chatham, NJ (http://www.robbinsinstruments.com)
Sklar Instruments, West Chester, PA (http://www.sklarcorp.com)
Surgical911.com, Old Saybrook, CT (http://www.surgical911.com)
Appendix B: Instruments and Materials in a Standard Gynecologic Tray
The following instruments and materials are included in the standard gynecologic tray:
Gloves
Graves metal speculum
Tenaculum
Uterine sound
Ring or sponge forceps
Basin with cotton balls and povidone-iodine
Add scalpel or scissors if needed
Add cervical dilators if needed
These items should be sterile for most procedures, except for removal of cervical polyps and treatment of Bartholin's gland abscesses.
The instruments can be ordered from the following sources:
Sklar Instruments, West Chester, PA (http://www.sklarcorp.com)
Surgical911.com, Old Saybrook, CT (http://www.surgical911.com)
Wallach Surgical Devices, Inc., Orange, CT (phone: 800-243-2463; http://www.wallachsurgical.com)
Appendix C: Recommended Suture Removal Times
The following times for suture removal are approximate. Patient factors such as age, presence of vascular or chronic disease, and
nutritional status influence healing times and suture removal times.
Face 3 to 5 days
Neck 5 to 7 days
Scalp 7 days
Trunk 10 to 14 days
Upper extremity 10 to 14 days
Extensor surface of the hands 14 days
Lower extremity 14 to 28 days
Appendix D: Suggested Tray for Soft Tissue Aspiration and Injection
Procedures
The following instruments and materials can be placed on a nonsterile sheet on the Mayo stand:
Nonsterile gloves
Fenestrated drape, if desired
Two 10-mL syringes
20- or 21-gauge, 1-inch needle for drawing up injecting solution
21-, 22-, or 25-gauge, 1 inch needle for aspiration or injection
1 inch of 4 4 gauze soaked with povidone-iodine solution
Hemostat for stabilizing the needle when exchanging the medication syringe for the aspiration syringe
1% lidocaine hydrochloride stock bottle (20 mL)
Steroid of choice (e.g., betamethasone sodium phosphate and acetate, 5-mL multiuse bottle)
Band-Aid or sterile bandage
For intraarticular injections and certain soft-tissue injections, it may be preferable to use sterile gloves, drapes, and tray. An assistant
should assist in drawing up the injecting solution to allow the practitioner to avoid contamination.
When using multiuse stock bottles, it is preferable to draw up the lidocaine first and then the steroid solution. This order prevents
contamination of the lidocaine with steroid that may be on the needle. Lidocaine on the needle does not significantly alter the steroid
solution.
Appendix E: Recommendations for Endoscope Disinfection
The following recommendations are offered for disinfection of endoscopes:
1. Every endoscopy should be performed with a clean, disinfected endoscope. Use of disposable-component systems (i.e., sheathed
endoscopes) can eliminate infectious transmission from endoscopes.
2. Manual cleaning of the endoscope's surface, valves, and channels is the most important step for preventing the transmission of
infections during endoscopy. Manual cleaning should occur immediately after each procedure to prevent drying of secretions or
formation of a biofilm, both of which may be difficult to remove. The endoscope should be immersed in warm water and detergent,
washed on the outside with disposable sponges or swabs, and brushed on the distal end with a small toothbrush. Valves should be
removed and cleaned by brushing away adherent debris, and the hollow portions should be flushed with detergent solution. The
biopsy-suction channel should be thoroughly cleaned with a brush that is appropriate for the instrument and channel size. Automatic
washing devices can be used but do not replace manual cleaning.
3. Disinfection can be achieved by soaking the endoscope, valves, and all internal channels for at least 10 minutes in 2%
glutaraldehyde. Many authorities prefer a minimum of 20 minutes. Alternately, newer systems that use acidic electrolytic water
(AEW) may achieve disinfection with less potential for subsequent tissue irritation or toxicity.
4. Endoscope channels should be rinsed with 70% alcohol, dried with compressed air, and hung vertically overnight to reduce bacterial
colonization when the endoscopes are not in use.
5. Accessories such as biopsy forceps should be mechanically cleaned and autoclaved after each use.
BIBLIOGRAPHY
Axon AT. Working party report to the World Congresses. Disinfection and endoscopy: summary and recommendations. J
Gastroenterol Hepatol 1991;6:2324.
Nelson D. Newer technologies for endoscope disinfection: electrolyzed acid water and disposable-component endoscope systems.
Gastrointest Endosc Clin North Am 2000;10: 319328.
Spach DH, Silverstein FE, Stamm WE. Transmission of infection by gastrointestinal endoscopy and bronchoscopy. Ann Intern Med
1993;118:117128.
Tandon RK. Disinfection of gastrointestinal endoscopes and accessories. J Gastroenterol Hepatol 2000;15(Suppl):S69S72.
Appendix F: Guidelines for Monitoring the Patient Receiving Conscious
Sedation for Gastrointestinal Endoscopy
The following guidelines are provided for monitoring patients who receive conscious sedation while undergoing gastrointestinal endoscopy:
1. Monitoring of patients is one part of an overall quality assessment program for the endoscopy unit. Monitoring policies should be
periodically evaluated and updated.
2. A well-trained gastrointestinal assistant, working closely with the endoscopist, is the most important part of the monitoring process.
The assistant and endoscopist should work as a team in assessing the patient's status and in responding to changes in clinical
parameters.
3. The use of monitoring equipment is a useful adjunct to patient surveillance but is never a substitute for conscientious clinical
assessment. Rapid visual assessment of the patient's skin color, breathing pattern, and level of comfort with the procedure may
provide useful information during the procedure.
4. The amount of monitoring should be proportional to the perceived risk to the patient from the procedure. Minimal clinical monitoring
for all sedated patients includes periodic evaluation of blood pressure, heart rate, and respiratory rate before, during, and after the
procedure, as well as at the time of discharge from the endoscopy unit. Consensus does not exist for monitoring cardiac rhythm and
oxygen saturation. Routine monitoring with electrocardiograms and oximetry is recommended by many authorities, but selective use
of these monitoring modalities can be performed for patients with known comorbidities (e.g., cardiac disease).
5. Oxygen administration before and during conscious sedation reduces the incidence of desaturation episodes during the procedure.
Oxygen administration is advocated for individuals with cardiovascular or pulmonary compromise and may be of value when
routinely administered to elderly individuals (>65 years old).
6. The primary modification in conscious sedation practices required for the geriatric population is administration of fewer agents at a
slower rate and to a
lower cumulative dose. Reversal agents (e.g., flumazenil, naloxone) should be readily available in the endoscopy unit.
BIBLIOGRAPHY
Eisen GM, Chutkan R, Goldstein JL, et al. Modifications in endoscopic practice for the elderly. Gastrointest Endosc 2000;52:849851.
Fleisher D. Monitoring the patient receiving conscious sedation for gastrointestinal endoscopy: issues and guidelines. Gastrointest
Endosc 1989;35:262266.
Appendix G: Suggested Anesthesia Tray for Administration of Local
Anesthesia, Nerve Blocks, Field Blocks, or Digital Blocks
The following items are placed on a nonsterile sheet covering the Mayo stand:
Nonsterile gloves
Povidone-iodine solution soaked into a 4 4 gauze (or in a sterile basin)
5- or 10-mL syringe
20- or 21-gauge, 1-inch needle for drawing anesthetic from the stock bottle
25-, 27-, or 30-gauge, inch or 1-inch needle for administering anesthetic
1 inch of nonsterile 4 4 gauze
1% lidocaine hydrochloride with or without epinephrine (choice determined by procedure and site of administration)
Antibiotic ointment and Band-Aid if no procedure will follow at the injection site
All of the items are readily available through local pharmacies, hospital purchasing groups, or surgical supply houses.
Appendix H: Skin Preparation Recommendations
Patient characteristics associated with an increased risk of surgical site infections include remote site infections, colonization, diabetes,
cigarette smoking, systemic steroid use, obesity, extremes of age, poor nutritional status, and preoperative transfusion of certain blood
products. Apply greater vigilance when performing office procedures on patients with these risk factors.
Preoperative shaving for hair removal is associated with higher rates of surgical site infections. Clipping hair immediately before a surgical
procedure has the lowest rates of associated infection and should be considered the preferred preparatory activity for hair removal.
Several effective antiseptic agents are available for preoperative skin preparation, including alcohol-containing products, the iodophors
(e.g., povidone-iodine), and chlorhexidine gluconate:
Alcohol is readily available, inexpensive, and the most rapid-acting skin antiseptic. Disadvantages include potential for spores to be
resistant, and potential for flammable reactions
Iodophors provide broad-spectrum coverage, are associated with lack of microbial resistance, and provide a bacteriostatic effect as
long as it exists on the skin
Chlorhexidine gluconate offers broad-spectrum coverage, appears to provide greater reductions in skin microflora than povidone-
iodine, and has greater residual activity after a single application
The following recommendations are provided for applying skin preparation agents:
Remove gross contamination from the skin, including soil, debris, or devitalized tissue.
Apply the skin-cleansing agent in concentric circles, starting from the intended surgical site.
Extend the area of skin cleansing to a wide enough area to cover the proposed operation, allowing for extension of the surgical field
for the creation of additional incisions or drains.
Do not rub or scrub the skin during application of the antiseptic agent. Damaging the skin during application can lead to increased
surgical site infections.
BIBLIOGRAPHY
Kaye ET. Topical antibacterial agents. Infect Dis Clin North Am 2000;14:321339.
Mangram AJ. Guidelines for prevention of surgical site infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital
Infection Control Practices Advisory Committee. Am J Infect Control 1999;27:97132.
Appendix I: Bacterial Endocarditis Prevention Recommendations
Endocarditis is a relatively uncommon, life-threatening disease that may result in substantial morbidity and mortality. Endocarditis usually
develops in individuals with underlying structural cardiac defects who develop bacteremia (Table 1). Although bacteremia is common after
many invasive procedures, only certain bacteria commonly cause endocarditis. Most cases of endocarditis are not attributable to an
invasive procedure.
Primary prevention of endocarditis should be attempted, whenever possible. If patients have a cardiac condition that puts them at
moderate or high risk for endocarditis and undergo a procedure that puts them at risk for bacteremia (Table 2), the American Heart
Association recommends prophylactic antibiotics (Table 3). To reduce the likelihood of microbial resistance, it is important that prophylactic
antibiotics be used only during the perioperative period. They should be initiated shortly before a procedure and should not be continued
for more than 6 to 8 hours afterward. In the case of delayed healing or of a procedure that involves infected tissue, it may be necessary to
provide additional doses of antibiotics for treatment of the established infection.
TABLE 1. CARDIAC CONDITIONS ASSOCIATED WITH RISK FOR BACTERIAL ENDOCARDITIS
High-risk individualsprophylaxis recommended
Prosthetic heart valves
History of endocarditis (even in the absence of other heart disease)
Complex cyanotic congenital heart disease
Surgically constructed systemic pulmonary shunts or conduits
Moderate-risk individualsprophylaxis recommended
Congenital cardiac conditions, including patent ductus arteriosus, ventricular septal defect,
primum atrial septal defect, coarctation of the aorta, and bicuspid aortic valve
Acquired valvar dysfunction (rheumatic heart disease or collagen vascular disease)
Hypertrophic cardiomyopathy
Mitral valve prolapse (MVP) with prolapsing and leaking mitral valves, evidenced by audible
clicks and murmurs of mitral regurgitation or by Doppler-demonstrated mitral insufficiency
Careful evaluation is required in children who have isolated clinical findings, such as nonejection
systolic click, since this may be the only indicator of important mitral valve abnormality requiring
prophylaxis
Negligible-risk individualsprophylaxis not recommended
MVP with normal mitral valves, prolapse without leaking, no murmurs, or minimal Doppler-
demonstrated mitral regurgitation
Pediatric patients with innocent heart murmurs
Isolated secundum atrial septal defect
Surgical repair of atrial septal defect, ventricular septal defect, or patent ductus arteriosus
(without residual beyond 6 months)
Previous coronary artery bypass graft surgery
Previous Kawasaki disease without valvar dysfunction
Previous rheumatic fever without valvar dysfunction
Cardiac pacemakers (intravascular and epicardial and implanted defibrillators)
TABLE 2. BACTEREMIA-PRODUCING PROCEDURES AND AMERICAN HEART ASSOCIATION RECOMMENDATIONS FOR
BACTERIAL ENDOCARDITIS PROPHYLAXIS
Bacterial Endocarditis Prophylaxis Recommended
Respiratory tract procedures
Tonsillectomy or adenoidectomy
Operations involving respiratory mucosa
Rigid bronchoscopy
Gastrointestinal tract procedures
Esophageal stricture dilatation
Endoscopic retrograde cholangiography
Sclerotherapy for esophageal varices
Biliary tract surgery
Surgery that involves intestinal mucosa
Genitourinary tract procedures
Cystoscopy
Prostatic procedures or surgery
Urethral dilatation
Removal of an infected intrauterine device
Bacterial Endocarditis Prophylaxis Not Recommended
Respiratory tract procedures
Endotracheal intubation
Flexible bronchoscopy
Tympanostomy tube insertion
Gastrointestinal tract procedures
Endoscopic ligation (banding) of varices
Transesophageal echocardiography
Endoscopy with or without gastrointestinal biopsy
Genitourinary tract procedures
Vaginal hysterectomy
Normal vaginal delivery
Cervical biopsy
Cesarean section
Urethral catheterization in uninfected tissue
Uterine dilation and curettage in uninfected tissue
Therapeutic abortion in uninfected tissue
Sterilization procedures in uninfected tissue
Insertion or removal of intrauterine devices in uninfected tissue
Circumcision
Cardiac procedures
Cardiac catheterization, including balloon angioplasty
Implanted cardiac pacemakers, defibrillators, and coronary stents
Dermatologic procedures
Incision or biopsy of surgically scrubbed skin
TABLE 3. RECOMMENDED PROPHYLACTIC ANTIBIOTIC REGIMENS
Condition Prophylactic Antibiotic Regimens
Standard, general
prophylaxis
Amoxicillin: adults, 2.0 g; children, 50 mg/kg PO 1 hr before
procedure
Patient unable to take oral
medications
Ampicillin: adults, 2.0 g IM or IV; children, 50 mg/kg IM or IV
within 30 min before procedure
Allergic to penicillin
Clindamycin: adults, 600 mg; children, 20 mg/kg PO 1 hr
before procedure
Cephalexin or cefadroxil: adults, 2.0 g; children, 50 mg/kg PO 1
hr before procedure
Azithromycin or clarithromycin: adults, 500 mg; children, 15
mg/kg PO 1 hr before procedure
Clindamycin: adults, 600 mg; children 20 mg/kg IV within 30
min before procedure
Cefazolin: adults, 1.0 g; children, 25 mg/kg IM or IV within 30
min before procedure
High-risk patient undergoing
GI or GU procedure
Adults: 2.0 g of ampicillin IM or IV plus 1.5 mg/kg of gentamicin
(not to exceed 120 mg) within 30 min before procedure; 6 hr
later, 1 g of ampicillin IM or IV or 1 g of amoxicillin PO
Children: 50 mg/kg of ampicillin IM or IV (not to exceed 2.0 g)
plus 1.5 mg/kg of gentamicin within 30 min before the
procedure; 6 hr later, 25 mg/kg of ampicillin or 25 mg/kg of
amoxicillin PO
High-risk patient undergoing
GI or GU procedure and
allergic to ampicillin or
amoxicillin
Adults: 1.0 g of vancomycin IV over 1-2 hr plus 1.5 mg/kg of
gentamicin IV or IM (not to exceed 120 mg), with complete
injection or infusion within 30 min before procedure
Children: 20 mg/kg of vancomycin IV over 12 hr plus 1.5
mg/kg of gentamicin IV or IM, with complete injection or
infusion within 30 min before procedure
Moderate-risk patient
undergoing GI or GU
procedure and allergic to
ampicillin or amoxicillin
Adults: 1.0 g of vancomycin IV over 12 hr, with complete
infusion within 30 min before procedure
Children: 20 mg/kg of vancomycin IV over 12 hr, with
complete infusion within 30 min before procedure
GI, gastrointestinal; GU, genitourinary.
Adapted from Dajani AS, Taubert KA, Wilson W, et al. Prevention of bacterial endocarditis. JAMA
1991;227:17941801.
Appendix J: Informed Consent
The principle of self-determination is the cornerstone of the American legal system. Rooted within this principle is the doctrine of informed
consent, which posits that an individual has the right to receive adequate information to form an intelligent decision regarding a proposed
procedure. Although the information included in informed consent varies from state to state, the key component that must be included is
what a reasonable patient would need to know about the risks of a proposed procedure that would cause the patient not to undergo that
treatment.
There are several key issues:
The medical record is considered a faithful documentation of what information was transmitted to the patient; the medical
professional must provide complete notes.
Courts assume that if it's not written, it didn't happen.
The physician's word that informed consent occurred is not sufficient.
All preoperative discussions about a procedure should be documented, including phone calls the night before a procedure.
There are exceptions to the need to obtain informed consent, including emergency care when immediate treatment is required to
prevent death or serious harm to the patient.
To prevail in a negligence action, a patient must prove each of the following claims:
1. The physician had a duty to disclose certain information to the patient.
2. The physician did not disclose the information (i.e., breach of duty).
3. The patient was harmed by the treatment.
4. The harm was the result of undisclosed risk.
5. The patient would have refused the procedure had the risk been disclosed.
BIBLIOGRAPHY
Moskop JC. Informed consent in the emergency department. Emerg Med Clin North Am 1999;17:327340.
Weintraub MI. Documentation and informed consent. Neurol Clin 1999;17:371381.