Nail

HISTORY:
provided by patient SO/family member present during visit chaperon/MA present during visit interpretation provided by family member/SO interpretation provided by MA complete history unobtainable d/t poor effort/affect complete history unobtainable d/t cognitive changes or lack of knowledge complete history unobtainable d/t language skills

CC:
ingrown toenail nail infection subungual hematoma nail plate discoloration partial nail avulsion complete nail avulsion

LOCATION: first second third fourth fifth medial side lateral side nail base nail side

HPI:
started more than 1 week ago started several days ago similar sx before had toenail removed by podiatry had toenail removed in urgent care was seen by pcp/urgent care taking abx doing warm soaks

PMSH:
noncontributory previous injuries/procedures PAD diabetes immunosuppression

TETANUS:
up to date less than five years ago 5-10 years ago greater than 10 years ago unknown

REVIEW OF SYSTEMS: [+] reported [-] not reported
negative except as stated in HPI
CONSTITUTIONAL:

objective fever subjective fever chills
EYES:

change in vision photophobia periorbital swelling pain with EOM
EARS:

pain bleeding tinnitus decreased in hearing
NOSE:

discharge bleeding
MOUTH/THROAT:

bleeding tongue pain/swelling sore throat odynophagia hoarseness
NECK:

pain stiffness swelling swollen glands
CV:

chest pain/pressure dyspnea orthopnea ankle swelling ankle discoloration leg cramps
CHEST/RESPIRATORY:

chest tightness pain w/ breathing rib pain cough
GI:

poor appetite nausea vomiting abdominal pain constipation diarrhea
GU:

dysuria hematuria retention oliguria
NEURO:

dizziness vertigo poor balance abnormality of walk focal weakness blackouts seizures tingling/numbness
PSYCH:

irritability confusion depression anxiety mood swings memory loss insomnia
LYMPH/HEMA:

gland swelling bruising anticoagulation DVT/clotting anemia autoimmune dz h/o cancer

Appearance:
well-appearing alert allows exam crying but consolable no apparent distress while getting on/off exam table & walking around exam room ill-appearing diaphoretic guarding poor cooperation with exam drowsy appears impaired slumped

Head/Face:
normocephalic no evidence of trauma no facial tenderness symmetrical face CN grossly intact

Eyes:
clear conjunctiva w/o exudates or hemorrhage, EOM intact without nystagmus visual acuity grossly intact cornea(s) clear glasses contacts conjunctival injection epiphora periorbital swelling dysconjugate gaze

Ears:
symmetrical & intact auricles bilaterally hearing to conversation intact clear canals without erythema or blood TMs normal in appearance

Nose:
nares patent bilaterally septum midline mucosa pink & moist mucosal edema clear discharge active septal hemorrhage dried up blood

Mouth/Throat:
normal voice moist oral mucosa without lesions or injury patent pharynx w/o swelling or exudates hoarseness tooth decay upper denture lower denture pharyngeal erythema w/o exudates pharyngeal crowding tonsillar enlargement

Neck:
symmetric with free painless ROM no LAD anterior LAD posterior LAD nuchal tenderness

Chest/Lungs:
normal work of breathing, symmetrical chest expansion chest wall atraumatic and non-tender clear and equal breath sounds bilaterally poor effort coughing

CV:
regular rhythm no murmurs no ankle edema pedal skin warm with good & equal pulses tachycardia irregular heart rhythm murmur calf tenderness ankle edema varicosities stasis discoloration

Abdomen:
not examined normal visual inspection, no distension normal active bowel sounds soft non-tender protruding surgical scar umbilical hernia diffuse tenderness over entire abdomen w/o RRG

GU:
not examined no suprapubic tenderness no CVAT bilaterally normal external genitalia no inguinal LAD

Behavior:
calm, pleasant, respectful allows exam cooperative with exam poor cooperation with exam guarded anxious fearful suspicious hypervigilant irritable frustrated restless labile sighing crying agitated raising voice defensive argumentative hostile forceful intense euphoric insisting on particular medication, test, referral, or accommodation withdrawn indifferent appears to be responding to internal psychotic process

Psychomotor Activity:
no involuntary movements tremor tardive dyskinesia tics bradykinetic fidgeting picking skin twirling hair cracking knuckles threatening posture/movement grimacing, furrowing eyebrows tightening jaw breathing hard shaking extremities clenching fists intense staring standing up and/or pacing opening door to hallway exited exam room during exam

Speech/Vocalization:
appropriate for age clear & coherent slurred monotonous stuttering hypoverbal hyperverbal loud soft slow rapid pressured repetitious questions cursing, swearing criticisms of staff direct threats indirect threats

NAIL PLATE:
intact subungual hematoma yellow injured

SURROUNDING SKIN/CUTICLE:
normal induration swelling tenderness erythema abscess

REGIONAL:
normal lymphangitis LAD

PLAN OF CARE:
POC risks/benefits/alternatives discussed with patient/parent/SO, opportunity provided to ask questions verbalized understanding of and agreement with POC, discharge & f/u instructions did not agree with my POC/recommendations – will seek second opinion/further care elsewhere

PREP:
N/A tourniquet applied draped to expose area povidone-iodine applied

ANESTHESIA:
N/A digital block lido 1% 3 mL on each side injected

PROCEDURE:
none subungual hematoma drained nail bed repaired with absorbable sutures nail plate repaired with non-absorbable sutures partial avulsion completed to lateral aspect of nail plate partial avulsion completed to medical aspect of nail plate area probed and inspected for nail fragments ablated with phenol 30 sec x3 antibacterial ointment applied covered with non-adherent dressing applied bulky gauze dressing patient tolerated procedure well

RX:
none electronic paper given to MA to be transmitted to pharmacy

REVIEWED:
MA notes med list previous visits PMP/CURES previous laboratory studies previous diagnostic studies specialty reports hospital discharge

VERBALLY INSTRUCTED ON:
vital signs/exam findings/recommendations x-ray findings wound check in 2 days return immediately for increasing pain, swelling, redness, drainage, fever keep wound dry remove packing in 24 hours daily warm soaks daily dressing change controlling chronic conditions smoking cessation weight loss

WORK/SCHOOL STATUS:
N/A fit for duty w/o restrictions fit for duty with restrictions no PE/gym excuse provided

BARRIERS TO CARE:
none identified poor cooperation with exam lack of motivation negative attitude to diagnostic impression & proposed tx incomplete history vague shifting complaints history not supported by objective findings poor compliance with POC multiple comorbidities polypharmacy lack of interest in nonpharmacologic therapies overwhelming focus on Rx drugs intolerance of multiple meds frequent ER/UC visits altered mental status hostile/disruptive behavior active psychiatric diagnosis alcohol or substance use social/cultural barriers victim of abuse perseveration flight of ideas preoccupation with illness catastrophization overgeneralization unrealistic beliefs negativism pessimism blaming others staff splitting

DISPOSITION:
RTC as discussed, sooner if condition worsens or new symptoms arise RTC for wound check in 48-72 hours referred to ER for immediate treatment via 911 referred to ER for immediate treatment via private transport declined emergency transfer left facility before being discharged asked to leave clinic

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