Althe Discussion: My proposed service for Bellevue Hospital “Mental health program that focuses on LGBTQIA+ Youth” (NYC Health + Hospitals, 2022,). This program would include counseling that will help them manage stress and depression, suicide prevention, substance abuse, homelessness and other services (Trevor Project, n.d).  LGBTQIA+  youth may encounter some “negative health and life outcomes”, so it is crucial for them to have access to these and as many other services as possible (Centers for Disease Control and Prevention, 2020).   The negative health and life outcomes LGBTQIA+ Youth experiences are issues with coming out to their friends and or family, social or fear rejection, they may experience violence, some form of trauma as well as inadequate mental or medical care (D’Amore Mental Health, n.d).  By offering these services Bellevue Hospital can help with making a difference in the health and social disparities LGBTQIA+ youths face. My focus on two of the five Ps of health care marketing. For this program I will use two of the five P’s of healthcare marketing “physicians and patients” (Cellucci et al., 2014).  The ones that will be utilizing these services are the patients.  This program will focus on supporting the needs of these patients and assures them that they have all the support services available to them. The two of the Five Ps that I can apply my proposal is public and patients.  The public health of the LGBTQIA+ Youth population would be affected the most from this proposed service.  Such as homelessness, substance abuse and suicide can affect the community.  Public health, “aims to improve the health and well-being of a group or a population”, not person (Cellucci et al., 2014). References: Cellucci, L. W., Wiggins, C., & Farnsworth, T. J. (2014).  Healthcare marketing: A case study approach. VitalSource Bookshelf version. vbk://9781567936056 Centers for Disease Control and Prevention, (2020, December).  LGBT youth resources.  https://www.cdc.gov/lgbthealth/youth-resources.htm D’Amore Mental Health. (n.d).  Mental health issues in LGBTQ youth.https://damorementalhealth.com/mental-health-issues-in-lgbtq-youth/ Trevor Project, (n.d).  Mental health: You matter. Let’s keep you thriving. https://www.thetrevorproject.org/resources/page/2/?s=Mental%20Health NYC Health + Hospitals, (2022, Octobe r).  Community health needs assessment 2022.https://hhinternet.blob.core.windows.net/uploads/2022/10/2022-CHNA-ISP-Report.pdf Reply to Thread Sharon Discussion The proposed service chosen for Bellevue Hospital NYC’s Behavioral Health Department is transcranial magnetic stimulation (TMS). TMS is a treatment for depression for patients who do not respond to other medication and therapies. TMS is a “noninvasive procedure that uses magnetic fields to stimulate nerve cells in the brain to improve symptoms of depression.” (Mayo Clinic, 2018) The treatment inv.

1. Althe Discussion:
My proposed service for Bellevue Hospital “Mental health
program that focuses on LGBTQIA+ Youth” (NYC Health +
Hospitals, 2022,). This program would include counseling that
will help them manage stress and depression, suicide
prevention, substance abuse, homelessness and other services
(Trevor Project, n.d). LGBTQIA+ youth may encounter some
“negative health and life outcomes”, so it is crucial for them to
have access to these and as many other services as possible
(Centers for Disease Control and Prevention, 2020). The
negative health and life outcomes LGBTQIA+ Youth
experiences are issues with coming out to their friends and or
family, social or fear rejection, they may experience violence,
some form of trauma as well as inadequate mental or medical
care (D’Amore Mental Health, n.d). By offering these services
Bellevue Hospital can help with making a difference in the
health and social disparities LGBTQIA+ youths face.
My focus on two of the five Ps of health care marketing.
For this program I will use two of the five P’s of healthcare
marketing “physicians and patients” (Cellucci et al., 2014). The
ones that will be utilizing these services are the patients. This
program will focus on supporting the needs of these patients
and assures them that they have all the support services
available to them. The two of the Five Ps that I can apply my
proposal is public and patients. The public health of the
LGBTQIA+ Youth population would be affected the most from
this proposed service. Such as homelessness, substance abuse
and suicide can affect the community. Public health, “aims to
improve the health and well-being of a group or a population”,
not person (Cellucci et al., 2014).
References:
Cellucci, L. W., Wiggins, C., & Farnsworth, T. J. (2014).
Healthcare marketing: A case study
approach. VitalSource Bookshelf version. vbk://9781567936056

2. Centers for Disease Control and Prevention, (2020, December).
LGBT youth resources.
https://www.cdc.gov/lgbthealth/youth-resources.htm
D’Amore Mental Health. (n.d).
Mental health issues in LGBTQ
youth.https://damorementalhealth.com/mental-health-issues-in-
lgbtq-youth/
Trevor Project, (n.d).
Mental health: You matter. Let’s keep you
thriving. https://www.thetrevorproject.org/resources/page/2/?s=
Mental%20Health
NYC Health + Hospitals, (2022, Octobe
r). Community health needs assessment
2022.https://hhinternet.blob.core.windows.net/uploads/2022/10/
2022-CHNA-ISP-Report.pdf
Reply to Thread
Sharon Discussion
The proposed service chosen for Bellevue Hospital NYC’s
Behavioral Health Department is transcranial magnetic
stimulation (TMS). TMS is a treatment for depression for
patients who do not respond to other medication and therapies.
TMS is a “noninvasive procedure that uses magnetic fields to
stimulate nerve cells in the brain to improve symptoms of
depression.” (Mayo Clinic, 2018) The treatment involves
placing an electromagnetic coil on the patient’s scalp close to
their forehead. The painless procedure allows the electromagnet
to deliver magnetic pulses which stimulates the nerve cells in
the area of the brain that controls mood and depression. The
goal is to trigger sections of the brain that decrease depression
activity.
Physicians and patients are two of the Five Ps that will be
applied to my final healthcare marketing and communication

3. plan. Marketing to physicians internally and externally will be
required. Education, compensation, and certification
information will be offered in the marketing campaign that will
be provided in a forum with experts in TMS to attract new
experienced physicians and psychiatrists to Bellevue Hospitals
NYC. The buy-in of staff physicians and psychiatrists will be
needed as they will market the service to their patients, who
have not had success with traditional treatments for depression.
The marketing campaign for patients would be through social
media advertisement. The advertisement would include a short
video to educate the patient. The education would include
patients who will need to be cleared before having TMS which
includes a psychiatric evaluation and a physical examination.
Additional marketing education would provide the following
warning and risk disclosures as well as the success rate and
benefits. The demographic would be chosen through predictive
analytics which are simulations that can identify existing trends
and direct studies and resources toward the desired targets.
Studies show that researchers are using behavioral and
linguistic indications from social media posts to create data that
identify the presence of mood and psychosocial
conditions. “Researchers in computer science (CS) are using
behavioral and linguistic cues from social media data to predict
the presence of mood and psychosocial disorders.” (Chancellor
& De Choudhury, 2020) This data will direct the social media
advertisement to the appropriate targets.
Chancellor, S., & De Choudhury, M. (2020). Methods in
predictive techniques for mental health status on social media: a
critical review.
Npj Digital Medicine,
3(1). https://doi.org/10.1038/s41746-020-0233-7
Mayo Clinic. (2018, November 27).
Transcranial Magnetic Stimulation - Mayo Clinic.
Mayoclinic.org. https://www.mayoclinic.org/tests-
procedures/transcranial-magnetic-stimulation/about/pac-

4. 20384625
Week 4
Skin Comprehensive SOAP Note Template
Patient Initials: _______ Age: _______
Gender: _______
SUBJECTIVE DATA:
Chief Complaint (CC):
History of Present Illness (HPI):
Medications:
Allergies:
Past Medical History (PMH):
Past Surgical History (PSH):
Sexual/Reproductive History:
Personal/Social History:
Health Maintenance:
Immunization History:

5. Significant Family History:
Review of Systems:
General:
HEENT:
Respiratory:
Cardiovascular/Peripheral Vascular:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Neurological:
Psychiatric:
Skin/hair/nails:
OBJECTIVE DATA:
Physical Exam:
Vital signs:
General:
HEENT:
Neck:
Chest/Lungs:.
Heart/Peripheral Vascular:
Abdomen:
Genital/Rectal:
Musculoskeletal:
Neurological:
Skin:
Diagnostic results:
ASSESSMENT:
PLAN: This section is not required for the assignments in this

6. course (NURS 6512), but will be required for future courses.
© 2021 Walden University
Page 2 of 3
Comprehensive SOAP Exemplar
Purpose: To demonstrate what each section of the SOAP note
should include. Remember that Nurse Practitioners treat
patients in a holistic manner and your SOAP note should reflect
that premise.
Patient Initials: _______ Age: _______
Gender: _______
SUBJECTIVE DATA:
Chief Complaint (CC): Coughing up phlegm and fever
History of Present Illness (HPI): Eddie Myers is a 58 year old
African American male who presents today with a productive
cough x 3 days, fever, muscle aches, loss of taste and smell for
the last three days. He reported that the “cold feels like it is
descending into his chest and he can’t eat much”. The cough is
nagging and productive. He brought in a few paper towels with
expectorated phlegm – yellow/green in color. He has associated
symptoms of dyspnea of exertion and fatigue. His Tmax was
reported to be 100.3, last night. He has been taking Tylenol
325mg about every 6 hours and the fever breaks, but returns
after the medication wears off. He rated the severity of her

7. symptom discomfort at 8/10.
Medications:
1.) Norvasc 10mg daily
2.) Combivent 2 puffs every 6 hours as needed
3.) Advair 500/50 daily
4.) Singulair 10mg daily
5.) Over the counter Tylenol 325mg as needed
6.) Over the counter Benefiber
7.) Flonase 1 spray each night as needed for allergic rhinitis
symptoms
Allergies:
Sulfa drugs - rash
Cipro-headache
Past Medical History (PMH):
1.) Asthma
2.) Hypertension
3.) Osteopenia
4.) Allergic rhinitis
5.) Prostate Cancer
Past Surgical History (PSH):
1.) Cholecystectomy 1994
2.) Prostatectomy 1986
Sexual/Reproductive History:
Heterosexual
Personal/Social History:
He has never smoked
Dipped tobacco for 25 years, no longer dipping
Denied ETOH or illicit drug use.

8. Immunization History:
Covid Vaccine #1 3/2/2021 #2 4/2/2021 Moderna
Influenza Vaccination 10/3/2020
PNV 9/18/2018
Tdap 8/22/2017
Shingles 3/22/2016
Significant Family History:
One sister – with diabetes, dx at age 65
One brother--with prostate CA, dx at age 62. He has 2
daughters, both in 30’s, healthy, living in nearby neighborhood.
Lifestyle:
He works FT as Xray Tech; widowed x 8 years; lives in the city,
moderate crime area, with good public transportation. He is a
college grad, owns his home and financially stable.
He has a primary care nurse practitioner provider and goes for
annual and routine care twice annually and as needed for
episodic care. He has medical insurance but often asks for drug
samples for cost savings. He has a healthy diet and eating
pattern. There are resources and community groups in his area
at the senior center but he does not attend. He enjoys golf and
walking. He has a good support system composed of family and
friends.
Review of Systems:
General: + fatigue since the illness started; + fever, no chills or
night sweats; no recent weight gains of losses of significance.
HEENT: no changes in vision or hearing; he does wear glasses
and his last eye exam was 6 months ago. He reported no history
of glaucoma, diplopia, floaters, excessive tearing or

9. photophobia. He does have bilateral small cataracts that are
being followed by his ophthalmologist. He has had no recent ear
infections, tinnitus, or discharge from the ears. He reported no
sense of smell. He has not had any episodes of epistaxis. He
does not have a history of nasal polyps or recent sinus infection.
He has history of allergic rhinitis that is seasonal. His last
dental exam was 1/2020. He denied ulceration, lesions,
gingivitis, gum bleeding, and has no dental appliances. He has
had no difficulty chewing or swallowing.
Neck: Denies pain, injury, or history of disc disease or
compression..
Breasts:. Denies history of lesions, masses or rashes.
Respiratory: + cough and sputum production; denied
hemoptysis, no difficulty breathing at rest; + dyspnea on
exertion; he has history of asthma and community acquired
pneumonia 2015. Last PPD was 2015. Last CXR – 1 month ago.
CV: denies chest discomfort, palpitations, history of murmur;
no history of arrhythmias, orthopnea, paroxysmal nocturnal
dyspnea, edema, or claudication. Date of last ECG/cardiac work
up is unknown by patient.
GI: denies nausea or vomiting, reflux controlled, Denies abd
pain, no changes in bowel/bladder pattern. He uses fiber as a
daily laxative to prevent constipation.
GU: denies change in her urinary pattern, dysuria, or
incontinence. He is heterosexual. No denies history of STD’s or

10. HPV. He is sexually active with his long time girlfriend of 4
years.
MS: he denies arthralgia/myalgia, no arthritis, gout or limitation
in her range of motion by report. denies history of trauma or
fractures.
Psych: denies history of anxiety or depression. No sleep
disturbance, delusions or mental health history. He denied
suicidal/homicidal history.
Neuro: denies syncopal episodes or dizziness, no paresthesia,
head aches. denies change in memory or thinking patterns; no
twitches or abnormal movements; denies history of gait
disturbance or problems with coordination. denies falls or
seizure history.
Integument/Heme/Lymph: denies rashes, itching, or bruising.
She uses lotion to prevent dry skin. He denies history of skin
cancer or lesion removal. She has no bleeding disorders,
clotting difficulties or history of transfusions.
Endocrine: He denies polyuria/polyphagia/polydipsia. Denies
fatigue, heat or cold intolerances, shedding of hair,
unintentional weight gain or weight loss.
Allergic/Immunologic: He has hx of allergic rhinitis, but no
known immune deficiencies. His last HIV test was 2 years ago.

11. OBJECTIVE DATA
Physical Exam:
Vital signs: B/P 144/98, left arm, sitting, regular cuff; P 90 and
regular; T 99.9 Orally; RR 16; non-labored; Wt: 221 lbs; Ht:
5’5; BMI 36.78
General: A&O x3, NAD, appears mildly uncomfortable
HEENT: PERRLA, EOMI, oronasopharynx is clear
Neck: Carotids no bruit, jvd or thyromegally
Chest/Lungs: Lungs pos wheezing, pos for scattered rhonchi
Heart/Peripheral Vascular: RRR without murmur, rub or gallop;
pulses+2 bilat pedal and +2 radial
ABD: nabs x 4, no organomegaly; mild suprapubic tenderness –
diffuse – no rebound
Genital/Rectal: pt declined for this exam
Musculoskeletal: symmetric muscle development - some age
related atrophy; muscle strengths 5/5 all groups.
Neuro: CN II – XII grossly intact, DTR’s intact
Skin/Lymph Nodes: No edema, clubbing, or cyanosis; no
palpable nodes
Diagnostics/Lab Tests and Results:
CBC – WBC 15,000 with + left shift
SAO2 – 98%
Covid PCR-neg
Influenza- neg
Radiology:
CXR – cardiomegaly with air trapping and increased AP
diameter
ECG
Normal sinus rhythm
Spirometry- FEV1 65%
Assessment:

12. Differential Diagnosis (DDx):
1.) Asthmatic exacerbation, moderate
2.) Pulmonary Embolism
3.) Lung Cancer
Primary Diagnoses:
1.) Asthmatic Exacerbation, moderate
PLAN: [This section is not required for the assignments in this
course, but will be required for future courses.]
© 2021 Walden University
Page 4 of 4
© 2021 Walden University
Page 3 of 4
Chapter JO I Nail Removal 41
Chapter
Nail Removal
Margaret R. Colyar
. r C.ode
11730-32 Nail removal, partial or complete
11750 Permanent nail removal, partial or complete
No code for cotton wick insertion-Use l 1730-32 if part of the

13. nail was removed.
An ingrown toenail occurs when the na il edge grows into the
soft tissues, causing
i111lammation, erythema, pain, and, possibly, abscess
formation (Fig. 10.1). Many
1imes rhere is an offending nail spicule (small needle-shaped
body) that must be
l'l'l110Ved.
OVERVIEW
• C;1uses
• C urved nails
Congeni tal malformation of the great toenail, an autosomal
dominant trait
Nails cut roo short
Nail trimmed round edges
Poorly fitting or too-tight shoes
High-heeled shoes
Accumulation of debris under nail
Poorly ventilated shoes
Chronically wet feet
HEALTH PROMOTION/PREVENTION
• Cut nails straight across.
• Notch center of nail with a V.
• Wt:ar absorbem socks.
• Wl:;1r shoes that allow proper ventilation.

14. • Wt:ar shoes thar flt properly.
• !void high-heeled shoes.
• J~t: good foot hygiene.
42 Section One I Dermatological Procedures
__,,.,~--:::::?" Dorsal cutaneous
nerves
-+-+--Dorsal deep
nerves
Hyponychium
Sulcus
Eponychium
(cuticle)
Figure 10.1 Toenail anatomy.
OPTIONS
• Method 1-Cotton wick insertion
• A noninvasive technique to be used as the initial treatment.
Six trearments
may be required.
• Method 2- Partial avulsion with phenolizat:ion
For lesions lasting more than 2 months with significant
infection and
development of granulomatous tissue

15. RATIONALE
• 'Ii> di111ini.~ l1 pain
• ·I( , p1·t·vrn1 m rdicvc . 1h.~n·~~ l(1rn1.11 ln11
Chapter 10 I Nail Removal 43
• To promote healing
• To prevent toenail regrowth
INDICATIONS
• Ingrown toenail without complicating medical history
(onychocryptosis)
• Chronic, rec urrent inflammation of the nail fo ld (paronychia)
CONTRAINDICATIONS
• Diaberes mellitus
• Peripheral vascular disease
• Peripheral neuropathy
• Anticoagulant therapy
• l31ccding abnormalities
• lmmunocompromised state
• Pregnancy because of need to use phenol
• Allergy to local anesthetics
l)ROCEDURE
Nail Removal
Equipment
• Mcrhod 1 only
Antiseptic skin cleanser
Nail file or emery board
Cotton: 3 mm (Vs-inch) thick by 2.5 cm (1 inch) long
( ;lovcs-nonsterile
Splinter forceps-sterile
T inctu re of iodine

16. Silv..:r nitrate stick
Ii x 4 gauze- sterile
·1:1 pc
• Mcd10cl 2 only-Digiral nerve block
'i -m L syringe
.~ )- to 27-gauge, Yi- to I-inch needle
I 1X1 liclocaine without epinephrine
• tvkd10<l 2-Avulsion
' li>11rniqlll:t
l :lovt:.~-srcrile
I )rape - src.:rilc
I lcmostat- stcrilc
Su rgid .~cissors-ster i lc
S11l:ll l s1 r:1igh1 hcmostar- stcl'lk•
• ( :011 on .~w:1hs-s1crilc
Sll w·1 11i1 r;11r stlc:i<
Hll11,i 111 HH'to plw1wl
http:l(1rn1.11
--

17. 44 Section One IDermatological Procedures
• Alcohol swabs
• Alcohol
• Antibiotic ointment (Bactroban, Bacitracin, or Polysporin)
• Nonadherent dressing-Telfa or Adaptic
• Bandage roll (tube gauze)
Procedure
METHOD I - COTTON WICK INSERTION
• Have the client lie supine with knees flexed and feet flat.
• Cleanse affected toe with antiseptic cleanser.
• File middle thi rd of nail on the affected side with a nail file
or emery board as
illustrated (Fig. 10.2).
• Roll cotton to form a wick.
• Gently push the cotron wick under the distal portion of d1e
lateral nail groove
on me affected side using splinrer forceps (Fig. 10.3) .
• Identify me offending spicule and remove it.
• Continue to insert cotton wick to separate the nail from the
nai l groove (1 cm
of cotron wick should remain free).
• Apply tincture of iodine to the cotton wick.
• Cauterize granulomarous tissue with silver nitrate stick.
• Bandage the toe.
Client Instructions
• Change bandage daily, and apply tincture of iodine every
omer day.
• Return to th e office weekly for cotton wick replacement.

18. METHOD 2-PARTIAL AVUI.SION WITH PHENOLIZATION
t lnjimned cowmt req11 ired
• Have the diem lie supine with knees flexed and feet flat.
• For digital nerve block, prepare 3 to 5 mL of lidocaine without
epinephrine to
anesmetize the affected area.
illl
I_.. -
naur~ 10.2 Fiie· tlw 111lddl1• tlilul 11f d11 tHll
Chapter JO INail Removal 45
--
Figure I 0.3 Gently push a conon wick
under d1e lateral nail groove.
• ' fo anesrl1etize th e nerves innervating the proximal
phalanx on th e extensor
surface, insert the needle toward the planrar surface on the
affected side.
• Injection sites are below the nail on me outer edges of the
toe (Fig. 10.4). Be
c:m:Ful not to pierce the plantar skin surface.
• Inject I 10 2 mL oflidocaine while withdrawing the needle. Do
not withdraw
1li e needle from the skin.
• Redirect rhe needle across the extensor surface, and insert me
needle further.

19. lnjecr 1 mL of lidocaine while wimdrawing needle.
• Repeat procedure on opposite side of the d igit.
• Allow 5 minutes for lidocaine to take effect before
beginning procedure.
• Sl't'u b rhc toe with antiseptic, rinse, dry, and drape with
sterile drapes.
• Place the tourniquet around the base of the toe. Perform
procedure in 15
111i11111cs or less to avoid ischemia.
• Inscl'I a single blade of a small hemostat between the nailbed
and the toe tO
op'n a tract (Fig. 10.5). Remove hemostat.
• l'l:in: thc blade of the scissors in the tract, and cut the nail
plate from disr;i l
1·dgc 10 1he proximal nail base (Fig. 10.6).
• llt·111ovc 1he nai l with a small hemostat, using genrle
rotation row:ird rhc
1 lfl i:~· 1 l·d nail (Pig. 10.7).
• l J,,lng a hcmos1a1, i11spccr rhe nail g1•onvt1 1111' ~p
lc11lcs.
• 1)1 )' di ~ 11nvly c.~ posd n:illhcd.
46 Section O ne I Dermatological Procedures
Figure I 0.4 Anesthetize the nerve innervating the proximal
phalanx. Inject the roe on the outer edges just below the
nail.
Figure I O.S Insen a single blade of a

20. hemostat between the nailbed and the toe
to open a tracr.
• Rub cotron swab saturated wi th phenol on germinal
matrix beneath the c111 il:k·
for 2 m inutes.
• Cauterize granulomas with silver nitrate stick.
• Remove ro11rniq11cl and cleva1 c font for 15 111i11u1 c~.
• Pl:11:e :1 dress I11g In ii1c Ille.
Chapter JO I Nail. Removal 47
Figure I 0.6 Cm the nail plate from distal edge co
proximal nail base.
Figure 10.7 Remove the nail using gen tle ou1ward
rotation toward the affected nail.
Client lnstrua ions
• Avoid bchc111 ia or !CW hy l1Jtl~l'lll 11 11 ili l
h.111d,1nl' :i 11d hangi ng roOI down.
• Nn1 Hy 11 1<· prar1l1lo1w1 ll' p,11 11 111Wdll11~11111r,1
'>l'~ nr gn:en 01· y(·llmv di~~'h.uw;
I'< j lrl'Sl' ll I.
http:di~~'h.uw
48 Section One I Dermatological Procedures
• If roes become cold and pale
Elevate foot above heart level
• Flex the roes

21. Check circulation by pressing on the roe and watching for
return of redness
when pressure is released
Call the practitioner if symptoms do not subside within 2 hours
• Use pain medications as ordered. Take Tylenol No. 3 every 4
to 6 hours for the
first 24 hours; then take an NSAID such as ibuprofen.
• Take ordered antibiotics for 5 days (cephalexin, tetracycl ine,
trimethoprim·
sulfamethoxawle, amoxicillin).
• Return to the office for follow-up visit in 2 days.
81 BLIOGRAPHY c:::;;:;=;;;;;;;;;;;;;::;;:;:;;;:;;.:::;;.:;::;...
Heidelbaugh JJ, Lee H. Management of rhe ingrown toenail. Am
Fam Physician.
2009;79(4):303-308.
Pfenninger JL, Fowler GC. Procedures for Primmy Care
Physicians. Sr. Louis, MO: Mosby;
2011.
Zuber TJ. Ingrown toenail removal. Am Fam Physician.
2002;65(12):2547-2550.
Chapter
Ring Removal
Cynthia R. Ehrhardt
( r C.o :le
20670 Superficial removal of constricting metal band
20680 Deep removal of constricting metal band

22. Occasionally, a ring must be removed from a digit. Whenever
possible, a nondesrruc-
cive method is preferred. Only when conservative methods have
been exhausted
should a ring cutter be used.
OVERVIEW
• Complicating factors
• Swelling or edema ro the digit
• Increased pain and sensitivity to area
• Embedding of metal filings into digit
General Principles
• Minimize 1hc amoun1 of pain.
• S11H>o1h 1ccl111iquc min imizes fo rt ht·r 1r:i 111ll:1 to
:11nt,
Section One
Dermatological Procedures
Chapter I
Punch Biopsy
Margaret R. Colyar
CPT Code
21550 Biopsy of soft t issue of neck or thorax
21920 Biopsy of soft tissue of back or flank, superficial
23066 Biopsy of soft tissue of shoulder; superficial

23. 24065 Biopsy of upper arm and elbow area
23066 Biopsy of soft tissue of forearm or wrist. superficial
27040 Biopsy of soft tissue of pelvis and hip area
27323 Biopsy of soft tissue of pelvis and hip area
27613 Biopsy of soft tissue of leg and ankle area
11 I00 Skin lesion-Depends on the srte, technique, and if benign
or malignant lesions
Biopsy is the removal ofa small piece of tissue from the skin for
microscopic exami-
nation. Partial or full thickness of skin over the lesion is
removed for evaluation.
OVERVIEW
Punch biopsy is used for full and partial dermal lesions such as
• Basal cell carcinoma
• Squamous cell carcinoma
• Actinic lceratoses
• Sebonheic keratoses
• Lcntigo (freckles)
• Lipomas
• Melanomas
• Nevi
• W:1rts- vcrruca vulgaris
i<ATIONALE
• 'th co11!hm cti<)logy ollcsion for ll'C11t mcnt
• '111 {"ll ahlJ.~h 01· conflr1n n d l.tf11HlS.I~ for
1Jr.t1'1111•111 nnd/or itHcrvention
2 3 Section One I Dermatological Procedures
INDICATIONS

24. • Partial- or full-dermal-thickness lesion not on the face, eye,
lip, or penis
CONTRAINDICATIONS
• Lesion on eyelid, lip, or penis, REFER ro a physician.
• Infection at the site of the biopsy
• Bleeding disorder
• Lesions that are deep or on the face, REFER to a physician.
t !11farmecl consent required
PROCEDURE
Punch Biopsy
Equipment
• Antiseptic skin cleanser
• Drape-sterile
• Gloves-sterile
• Disposable biopsy punch (Fig. 1.1 )
• Pickups-sterile
• Scissors-sharp for the fine tissue-sterile
• 3-mL syringe
• 27- to 30-gauge, Y2-inch needle
• 1% lidocaine
• Container with 10% formalin
• 4 x 4 gauze
Figure I. I Dl ~f li l~1d th itlllJ!.~Y
p1lllclws.
Chapter 1 I Punch Biopsy
• Nonstick dressing (Adaptic or Telfa)
• Kl ing

25. • Tape
• Steri-Strips (if biopsy will be greater than 4 mm) or one suture
Procedure
• Position the client so thac the area to be biopsied is easily
accessible.
• C leanse the skin with antiseptic skin cleanser.
• Puc on gloves.
• Drape the area ro be biopsied.
• Anesthetize wich 1% lidocaine.
• With the thumb and index finger, spread the skin to apply
tension opposite
natu ral skin tension lines. This allows a more elliptical-shaped
wound for easy
closure.
• Apply biopsy punch to skin, rotate per manufacturer's
directions, and remove
tfo:; punch (Fig. 1.2).
• Wi th pickups, pull up loosened skin.
• C ut with scissors, and place tissue in tissue container of 10%
formalin
(Fig. 1.3).
• If kss chan 2 to 3 mm, apply nonstick dressing and pressure
dressing.
• Ir greater than 4 mm , apply Steri-Srrips and cover with 4 x 4
gauze.
• /pply IUing and secure with tape.
Client Instructions

26. • l«.:q) dressing clean, dry, and in place fo r 48 hours to
decrease the chance of
I>!ced ing and oozing.
• / void rouching or contaminating the area biopsied.
• ' I(1 prevent the chance of infection, take cephalexin
(Keflex) 500 mg three times
11t·1· day or amoxicillin (Amoxil) 500 mg twice a day for 5
days.
-
(
II I
,._'¥,,) Flg1w~ 1.l Appl)1 hlo1)·~Y pt 111 d1 w skin a11d
1·01n1u,
4 Section One I D ermacological Procedures
Figure I .l Cut with scissors.
• Some redness, swelling, and heat are normal. Return co the
office if symptoms
of infection occur, such as
Yellow or green d rainage
• Red streaks
• Pain

27. • Elevated temperature
• Take acetaminophen (Tylenol) or ibuprofen (Motrin) every 4
to 6 hours as
needed for pain.
BIBLIOGRAPHY c;;;;;;;;;;;:======...::::......;
De Vries HJ, Zeegelaar JE, Middelkoop E, et al. Reduced
wound comracrion and scar
formation in punch biopsy wounds. Native collagen dermal
substitutes. A clinical study.
Br ] Dermatol. 1995;132(5):690-697.
Zuber TJ. Ingrown toenail removal. Am Fam Physician.
2002;65(1 2):2547-2550.
APA format with intext citation
3-5 scholarly references with in the last 5 years
Plagiarism free with Turnitin report
Properly identifying the cause and type of a patient’s skin
condition involves a process of elimination known as
differential diagnosis. Using this process, a health professional
can take a given set of physical abnormalities, vital signs,
health assessment findings, and patient descriptions of
symptoms, and incrementally narrow them down until one
diagnosis is determined as the most likely cause.
In this Lab Assignment, you will examine several visual
representations of various skin conditions, describe your
observations, and use the techniques of differential diagnosis to
determine the most likely condition.
To prepare

28. · Review the Skin Conditions document provided in this week’s
Learning Resources, and select one condition to closely
examine for this Lab Assignment. PLEASE SEE
ATTACHEMENT FOR SKIN CONDITIONS I have attached 2
chose one of them.
· Consider the abnormal physical characteristics you observe in
the graphic you selected. How would you describe the
characteristics using clinical terminologies?
· Explore different conditions that could be the cause of the skin
abnormalities in the graphics you selected.
· Consider which of the conditions is most likely to be the
correct diagnosis, and why.
· Review the Comprehensive SOAP Exemplar found in this
week’s Learning Resources to guide you as you prepare your
SOAP note. PLEASE SEE ATTACHEMTNS
· Download the SOAP Template found in this week’s Learning
Resources, and use this template to complete this Lab
Assignment. PLEASE SEE ATTACHEMTNS
THE LAB ASSIGNMENT
PLEASE SEE ATTACHEMENT FOR SKIN CONDITIONS I
have attached two chose one please
· Choose one skin condition graphic (identify by number in your
Chief Complaint) to document your assignment in the SOAP
(Subjective, Objective, Assessment, and Plan) note format
rather than the traditional narrative style. Refer to Chapter 2 of
the Sullivan text and the Comprehensive SOAP Template in this
week's Learning Resources for guidance. Remember that not all
comprehensive SOAP data are included in every patient case.
· Use clinical terminologies to explain the physical
characteristics featured in the graphic. Formulate a differential
diagnosis of five possible conditions for the skin graphic that
you chose. Determine which is most likely to be the correct
diagnosis and explain your reasoning using at least three
different references, one reference from current evidence-based

29. literature from your search and two different references from
this week’s Learning Resources.