# Clinical Cases: Office Procedures

## Case 1: Skin Lesion Evaluation and Excision

### Patient Demographics
- **Age:** 52 years old
- **Sex:** Male
- **Occupation:** Outdoor landscaper

### Chief Complaint
"I have this spot on my arm that's been changing. My wife is worried it might be cancer."

### History of Present Illness
Mr. David Reynolds is a 52-year-old landscaper presenting with a changing pigmented lesion on his left forearm. He first noticed the spot about 2 years ago and thought it was a "sun spot" or freckle. Over the past 6 months, he has noticed it has grown larger, developed an irregular border, and become darker with some variation in color. It does not itch or bleed. His wife has become increasingly concerned and urged him to come in.

### Past Medical History
- Hypertension, well-controlled
- History of multiple sunburns, including blistering sunburns as a teenager
- No prior skin cancers

### Family History
- Father: Basal cell carcinoma (multiple)
- No family history of melanoma

### Social History
- Works outdoors 8-10 hours daily
- Does not consistently use sunscreen
- Light skin type, freckles easily, does not tan well (Fitzpatrick Type I-II)
- Non-smoker

### Physical Examination of the Lesion

**Location:** Left dorsal forearm

**ABCDE Assessment:**
- **A - Asymmetry:** YES - one half does not match the other
- **B - Border:** Irregular, notched edges
- **C - Color:** Variegated - brown, tan, black, with areas of pink
- **D - Diameter:** 8 mm (larger than 6 mm pencil eraser)
- **E - Evolution:** YES - patient reports significant changes over 6 months

**Additional findings:**
- Flat (macular) without palpable elevation
- No ulceration or bleeding
- No satellite lesions
- No palpable regional lymphadenopathy (axillary)

### Clinical Image
![Melanoma ABCDE Criteria](case_01_image.jpg)

*Image: Visual demonstration of the ABCDE criteria for melanoma detection showing asymmetry, border irregularity, color variation, diameter greater than 6mm, and evolution over time.*

**Image Source:** Wikimedia Commons
**Attribution:** National Cancer Institute, Public Domain
**URL:** https://commons.wikimedia.org/wiki/File:Melanoma_ABCDE.jpg

### Clinical Impression
**High suspicion for melanoma** - lesion meets multiple ABCDE criteria in a high-risk patient (Fitzpatrick I-II, extensive sun exposure, family history of skin cancer)

### Management Decision: Excisional Biopsy

Given the high clinical suspicion for melanoma, an **excisional biopsy** is the appropriate approach (rather than shave or punch biopsy) to:
1. Provide complete histopathologic assessment including Breslow depth
2. Potentially serve as definitive treatment if margins are adequate and lesion is thin
3. Avoid transecting the lesion which could compromise staging

### Informed Consent Discussion

**Procedure explained:** Complete removal of the lesion with a small margin of normal-appearing skin

**Risks discussed:**
- Bleeding
- Infection
- Scarring
- Nerve damage (numbness around the wound)
- Need for re-excision if margins inadequate or melanoma confirmed
- Pathology may reveal malignancy requiring further treatment

**Benefits discussed:**
- Definitive diagnosis
- Potentially curative if lesion is benign or early melanoma with adequate margins

**Alternatives discussed:**
- Referral to dermatology for biopsy (appropriate alternative)
- Observation (not recommended given high clinical suspicion)

**Patient consented to procedure.**

### Procedure: Elliptical Excision

**Preparation:**
- Surgical site marking: ellipse oriented along relaxed skin tension lines (longitudinal on forearm)
- 2 mm clinical margins marked around visible lesion
- Ellipse designed with 3:1 length-to-width ratio to prevent dog ears
- Site cleansed with chlorhexidine
- Sterile field established

**Anesthesia:**
- 1% lidocaine with epinephrine
- Calculated maximum dose: 7 mg/kg = 560 mg for 80 kg patient
- Used approximately 5 mL (50 mg) - well within safe limits
- Field block around lesion (not through the lesion)
- Waited 5 minutes for vasoconstriction

**Excision:**
- Incision made along marked ellipse using #15 scalpel
- Incision extended to subcutaneous fat
- Specimen undermined and removed in one piece
- Hemostasis achieved with electrocautery

**Specimen handling:**
- Specimen oriented with marking suture at 12 o'clock (superior)
- Placed in 10% formalin
- Pathology requisition completed with clinical description, diagram, and differential diagnosis (melanoma vs. dysplastic nevus vs. other)

**Closure:**
- Wound undermined to reduce tension
- Deep layer: 4-0 Vicryl buried interrupted sutures
- Skin: 4-0 nylon simple interrupted sutures

**Post-procedure:**
- Wound cleaned and dressed with petrolatum and non-adherent dressing
- Patient instructed on wound care: keep dry 24-48 hours, then gentle cleaning, apply petrolatum and bandage daily
- Activity: avoid heavy lifting or strenuous arm use for 1 week
- Suture removal: 10-14 days (forearm)
- Signs of infection to watch for: increasing redness, warmth, swelling, purulent drainage, fever
- Follow-up scheduled for pathology results

### Pathology Result (returned 5 days later)

**Diagnosis: Malignant melanoma, superficial spreading type**
- Breslow thickness: 0.6 mm
- No ulceration
- Mitotic rate: 0/mm2
- Margins: Negative (closest margin 1.5 mm)
- No lymphovascular invasion

**Stage: T1a (thin melanoma, no ulceration, no mitoses)**

### Further Management

**Referral to surgical oncology/dermatology for:**
- Discussion of wide local excision (standard is 1 cm margins for melanoma ≤1 mm)
- Current margins may be adequate but specialist evaluation recommended
- Sentinel lymph node biopsy: generally not indicated for T1a melanoma <0.8 mm
- Surveillance plan

**Patient counseled on:**
- Excellent prognosis for thin melanoma (5-year survival >95% for T1a)
- Importance of full body skin examinations regularly
- Sun protection going forward
- Teaching family members about skin examination

### Teaching Points

1. **ABCDE criteria for melanoma:** Asymmetry, Border irregularity, Color variation, Diameter >6mm, Evolution/change

2. **Excisional biopsy is preferred for lesions suspicious for melanoma** - allows complete assessment including Breslow depth

3. **Breslow thickness is the most important prognostic factor** for melanoma

4. **Proper specimen handling:**
   - Orient the specimen
   - Place in formalin
   - Complete requisition with clinical information

5. **Elliptical excision principles:**
   - Orient along relaxed skin tension lines
   - 3:1 length-to-width ratio
   - Extend to subcutaneous fat
   - Undermine to reduce tension

---

## Case 2: Laceration Repair

### Patient Demographics
- **Age:** 28 years old
- **Sex:** Female
- **Occupation:** Chef

### Chief Complaint
"I cut my hand while slicing onions at work about an hour ago."

### History of Present Illness
Ms. Sarah Kim is a 28-year-old chef who sustained a laceration to her left index finger while cutting vegetables at work approximately 1 hour ago. She was using a sharp chef's knife which slipped and cut the palmar surface of her finger. There was moderate bleeding which she controlled with direct pressure. She denies loss of consciousness, other injuries, or contamination of the wound with foreign material. She removed her glove immediately and rinsed the wound with water before wrapping it.

### Past Medical History
- No chronic medical conditions
- No prior surgeries
- No known allergies
- Tetanus: Tdap 3 years ago

### Social History
- Non-smoker
- Occasional alcohol
- Right-hand dominant

### Physical Examination

**Vital Signs:** Normal

**Wound Examination (after cleaning):**
- Location: Palmar surface, left index finger, over middle phalanx
- Length: 2.5 cm, linear
- Depth: Through dermis, does not appear to involve tendon sheath
- Wound edges: Clean, sharp, well-approximated when pressed together
- Contamination: Clean wound, no visible foreign body
- Bleeding: Minimal with pressure applied

**Neurovascular Assessment:**
- Capillary refill: <2 seconds in fingertip
- Radial and ulnar digital pulses: Present
- Two-point discrimination: Intact at 5 mm on both sides of finger
- Sensation to light touch: Intact throughout
- Motor: Full active flexion and extension of DIP and PIP joints against resistance

**Tendon Assessment:**
- Flexor digitorum superficialis: Intact (tests by flexing PIP while holding other fingers extended)
- Flexor digitorum profundus: Intact (tests by flexing DIP while holding PIP extended)
- No tendon visible in wound base

### Clinical Image
![Laceration Assessment](case_02_image.jpg)

*Image: Illustration showing proper wound assessment technique including evaluation of wound depth, neurovascular status, and tendon function before repair.*

**Image Source:** Wikimedia Commons
**Attribution:** Medical illustration, Educational Use
**URL:** https://commons.wikimedia.org/wiki/File:Wound_assessment.png

### Assessment
1. **Simple laceration, left index finger** - clean, sharp wound appropriate for primary closure
2. No tendon, nerve, or vascular injury identified
3. Low infection risk: clean wound, early presentation, no contamination

### Procedure: Wound Repair

**Informed Consent:**
- Risks: Infection, bleeding, scarring, wound dehiscence, nerve damage, need for reoperation
- Benefits: Wound healing, reduced scarring, reduced infection risk
- Alternatives: Wound left to heal by secondary intention (not recommended for this location)
- Patient consented

**Anesthesia - Digital Block:**
- 1% lidocaine WITHOUT epinephrine (traditional teaching, though evidence supports epinephrine safety in digits)
- Digital block at base of finger: 2 mL injected on each side of the finger base to block digital nerves
- Waited 5 minutes for full anesthesia
- Confirmed anesthesia with pinprick testing

**Wound Preparation:**
- High-pressure irrigation with 150 mL normal saline via 35 mL syringe with 18-gauge angiocatheter
- Wound edges examined - minimal debridement needed
- Wound base examined under anesthesia - no tendon involvement confirmed

**Closure:**
- **5-0 nylon simple interrupted sutures**
- 4 sutures placed with 3-4 mm spacing
- Sutures placed 2-3 mm from wound edge, equal depth on both sides
- Wound edges everted
- Sutures tied with appropriate tension - approximating without strangulating

**Dressing:**
- Wound covered with non-adherent dressing (Adaptic)
- Gauze wrap applied
- Finger splinted in position of function for protection

**Tetanus Prophylaxis:**
- Tdap given 3 years ago
- Clean wound
- No tetanus booster needed (booster needed if >10 years for clean wound)

### Post-Procedure Instructions

**Wound Care:**
- Keep dressing clean and dry for 24-48 hours
- After 48 hours: May get wet briefly in shower, pat dry, apply thin layer of petrolatum ointment, cover with bandage
- Do not soak in water
- Elevate hand above heart level when possible for first 24-48 hours

**Activity:**
- Avoid heavy use of the hand for 7-10 days
- May return to non-cutting duties at work
- No handling raw meat or potentially contaminated materials until wound healed

**Warning Signs - Return Immediately If:**
- Increasing redness spreading beyond wound edges
- Increasing pain after first 24 hours
- Fever
- Purulent drainage
- Numbness or tingling in fingertip
- Color changes in fingertip (pale, blue)

**Follow-Up:**
- Suture removal in 10-14 days
- Sooner if any concerning symptoms

### Teaching Points

1. **Systematic wound assessment before repair:**
   - Mechanism, time since injury, contamination
   - Wound depth and structures involved
   - Neurovascular status (pulses, capillary refill, sensation)
   - Tendon function (active range of motion against resistance)

2. **Digital blocks provide excellent anesthesia for finger procedures**
   - Block both digital nerves at base of finger
   - Traditional teaching avoided epinephrine, but modern evidence supports its safety

3. **High-pressure irrigation is the most important step** to reduce wound infection risk

4. **Suture selection:**
   - Face: 6-0 non-absorbable, remove 3-5 days
   - Hand: 5-0 non-absorbable, remove 10-14 days
   - Trunk/extremities: 4-0 non-absorbable, remove 7-14 days

5. **Tetanus prophylaxis:**
   - Clean wounds: Booster if >10 years since last dose
   - Contaminated wounds: Booster if >5 years since last dose
   - Add tetanus immune globulin if <3 prior doses and dirty wound

6. **Wounds appropriate for primary closure:**
   - Clean wounds presenting within 6-12 hours (body)
   - Face: Up to 24 hours (excellent blood supply)
   - Exception: Bite wounds generally left open (except face)

---

## Case 3: Joint Injection - Knee Osteoarthritis

### Patient Demographics
- **Age:** 64 years old
- **Sex:** Female
- **Occupation:** Retired teacher

### Chief Complaint
"My knee arthritis is flaring up again. The pills aren't helping enough."

### History of Present Illness
Mrs. Patricia O'Brien is a 64-year-old woman with known bilateral knee osteoarthritis presenting with worsening right knee pain over the past 3 weeks. She describes the pain as a dull ache that worsens with activity, particularly climbing stairs and prolonged walking. She has morning stiffness lasting about 15-20 minutes. She has been taking naproxen 500 mg twice daily with modest relief. Physical therapy helped in the past but she has not been able to attend recently. She had a corticosteroid injection in this knee about 10 months ago with good relief lasting approximately 4-5 months.

### Past Medical History
- Bilateral knee osteoarthritis, right worse than left
- Hypertension
- Type 2 diabetes mellitus (well-controlled, A1c 6.9%)
- No allergies

### Current Medications
- Metformin 1000 mg twice daily
- Lisinopril 20 mg daily
- Naproxen 500 mg twice daily PRN

### Physical Examination

**Right Knee:**
- Inspection: Mild bony enlargement, no erythema, no significant effusion
- Palpation: Tenderness along medial joint line
- Range of motion: 5-115 degrees (mild limitation in full flexion)
- Crepitus present with range of motion
- Ligamentous stability: Intact
- No warmth compared to contralateral knee
- No Baker's cyst

**Left Knee:** Mild crepitus, less symptomatic

### Prior Imaging
X-rays from 1 year ago: Bilateral medial compartment joint space narrowing, osteophytes, right > left, Kellgren-Lawrence Grade 3

### Clinical Image
![Knee Joint Injection Anatomy](case_03_image.jpg)

*Image: Anatomical illustration showing the superolateral approach for knee joint injection, with needle placement 1 cm superior and 1 cm lateral to the superolateral pole of the patella.*

**Image Source:** Wikimedia Commons
**Attribution:** Medical illustration, Educational Use
**URL:** https://commons.wikimedia.org/wiki/File:Knee_injection_anatomy.png

### Assessment
1. **Osteoarthritis, right knee** - symptomatic flare, appropriate for intra-articular injection
2. Type 2 diabetes - counsel about transient glucose elevation

### Indication for Injection
- Moderate-severe symptomatic OA
- Inadequate relief with oral medications
- Prior good response to injection
- >3 months since last injection

### Procedure: Intra-articular Knee Injection

**Informed Consent:**
- Risks: Infection (rare, <1:10,000), bleeding, post-injection flare (transient pain increase in 12-36 hours), skin depigmentation at injection site, tendon weakening with repeated injections, temporary blood glucose elevation
- Benefits: Pain relief lasting weeks to months, improved function
- Alternatives: Continued oral medications, physical therapy, hyaluronic acid injection, surgical referral
- Patient consented

**Preparation:**
- Patient positioned supine with knee extended (or slight flexion with rolled towel)
- Superolateral approach selected
- Landmarks identified: Superior pole of patella, lateral edge of patella
- Skin marked at injection site: 1 cm superior and 1 cm lateral to superolateral pole of patella
- Skin cleansed with chlorhexidine, allowed to dry

**Injection:**
- 22-gauge, 1.5-inch needle attached to syringe containing:
  - Triamcinolone acetonide 40 mg (1 mL)
  - 1% lidocaine 4 mL (for volume and immediate relief)
- Needle inserted at 45-degree angle directed toward intercondylar notch
- Advanced until "give" felt entering joint space
- Aspirated - no blood or fluid obtained (small effusion would be aspirated and sent for analysis if present)
- Injected slowly with minimal resistance
- Needle withdrawn, pressure applied

**Post-Procedure:**
- Adhesive bandage applied
- Patient remained seated for 5 minutes
- Ambulated without difficulty

### Post-Injection Instructions

**Activity:**
- Rest the knee for 24-48 hours - avoid strenuous activity
- May resume normal activities gradually after 48 hours
- No prolonged standing or walking today

**Expected Course:**
- May experience soreness at injection site for 1-2 days
- Lidocaine provides immediate but temporary relief (wears off in hours)
- Steroid effect begins in 2-5 days, peaks at 1-2 weeks
- Duration of relief varies: weeks to months

**Diabetic Glucose Monitoring:**
- Blood glucose may be elevated for 3-5 days after injection
- Monitor glucose more frequently
- Contact office if glucose consistently >300 or symptoms of hyperglycemia

**Warning Signs - Return If:**
- Increasing pain, swelling, or redness after 48 hours
- Fever
- Unable to bear weight
- Warmth or redness of the knee

**Follow-Up:**
- Return in 4-6 weeks to assess response
- Consider physical therapy referral for strengthening and range of motion
- Limit frequency of injections to 3-4 per year per joint

### Teaching Points

1. **Corticosteroid injection indications:**
   - Symptomatic OA inadequately controlled with conservative measures
   - Joint inflammation (inflammatory arthritis, crystal disease)
   - Soft tissue inflammation (bursitis, tendinopathy)

2. **Technique pearls:**
   - Superolateral approach to knee is most commonly used
   - Enter 1 cm above and 1 cm lateral to superolateral patella
   - Aspiration before injection confirms intra-articular placement
   - If effusion present, aspirate before injecting steroid

3. **Frequency limits:** 3-4 injections per year per joint maximum to avoid cartilage damage and soft tissue atrophy

4. **Post-injection flare:** Occurs in ~10% of patients, typically 12-36 hours after injection, managed with ice and NSAIDs

5. **Contraindications:**
   - Suspected septic joint (absolute)
   - Overlying skin infection (absolute)
   - Uncontrolled coagulopathy (relative)
   - Recent joint replacement (relative - risk of infection)

6. **Diabetic patients:** Warn about transient glucose elevation lasting 3-7 days

---

## Key Teaching Points Summary

### Procedure Selection and Planning
- Clear indication required for every procedure
- Informed consent must include risks, benefits, alternatives
- Assess clinician competency - know when to refer

### Skin Procedures
- ABCDE criteria for melanoma evaluation
- Excisional biopsy preferred for suspected melanoma
- Elliptical excision: orient along relaxed skin tension lines, 3:1 ratio
- Proper specimen handling: orient, label, formalin, complete requisition

### Wound Care
- Systematic assessment: mechanism, depth, neurovascular status, tendon function
- High-pressure irrigation is the most important infection-prevention step
- Suture size and removal timing vary by location
- Tetanus prophylaxis assessment at every wound visit

### Joint Injections
- Limit to 3-4 per year per joint
- Sterile technique essential
- Know the anatomy and landmarks
- Warn diabetic patients about glucose elevation
- Post-injection flare is common and self-limited