CHIEF COMPLAINT: Toe injury.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old man who stated that he kicked a rock with his left foot today morning and suffered a partial avulsion of his first toenail. The patient states the bleeding was controlled at the site, and he had no other injury.
PAST MEDICAL HISTORY: COPD, asthma, coronary artery disease.
SOCIAL HISTORY: Nonsmoker, nondrinker. Lives alone.
MEDICATIONS: Albuterol.
ALLERGIES: None.
REVIEW OF SYSTEMS:
MUSCULOSKELETAL: Positive toe pain. No foot pain. No neck pain. No back pain.
HEMATOLOGIC: No bleeding or bruising.
INTEGUMENTARY: No skin rash or lesion.
NEUROLOGIC: No motor or sensory loss.
IMMUNIZATION: Up-to-date.
PHYSICAL EXAMINATION:
GENERAL APPEARANCE: On exam, this is a middle-aged man who is in no acute distress.
VITAL SIGNS: Blood pressure 128/62, heart rate 72, respiratory rate 22, temperature 98.6.
PULMONARY: Good respiratory effort.
MUSCULOSKELETAL: Full range of motion of joints; they were nontender. The left first toe, there was no swelling and there was no ecchymosis. There is positive range of motion of the metatarsophalangeal joint and the proximal phalangeal joint. There is positive partial avulsion of the nail. It was intact at the epionychium, but the perionychium on bilateral sides was disrupted. There was no active bleeding. There was no laceration that was noted and no foreign body that was noted.
NEUROLOGIC: Motor was intact. Sensory was intact.
INTEGUMENTARY: Warm and dry. Color normal. There is no rash or lesion. No purpura, no petechiae that was noted.
PROCEDURE: The wound was anesthetized with LAT first, which was placed on the nail bed. Then, the toe was anesthetized by myself with the digital block with 0.25% Marcaine without epinephrine and then the area was also locally infiltrated with Marcaine 0.25% without epinephrine. With good anesthetic effect, I was able to remove the nail in its entirety. The nail bed was cleansed. The cotton tissue was removed and the nail itself was debrided and trimmed. Iodoform gauze was placed on the nail bed with packing into the epionychium and then the nail was placed over the iodoform gauze. It could not be sutured to the foot due to the thickness of the nail, but it was approximated with tape and a dry sterile dressing was placed. The patient’s pain was tolerable. After the digital block, the patient stated that he had no pain.
DISCHARGE DIAGNOSIS: Nail avulsion and repair.
PLAN:
1. The patient was given instructions to clean the wound daily.
2. Keep the iodoform gauze on for the next several days and then he can remove the gauze and put antibiotic ointment.
3. He can use the old nail for protection until the new nail starts to grow in.
4. No swimming.
5. They are going to follow up for wound check in 4 days.
6. Ibuprofen and Vicodin for pain.
7. The patient left stable and ambulatory.
