TFP Thread

[Homo sapien]

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Since we're in TFP thread, you guys see Dr. Roth (yes, that paincur guy) rant in PM latest issue about patient with plantar fasciitis getting billed for an office visit and how that's "toxic billing" compared to his cash pay injection gig. Insert pot and kettle saying.

Wtf is wrong with an office visit

 

[air bud]

This is the most useful post on this entire forum in a while. Stuff we actually deal with on the daily.

What are ya'll doing for tendonitis, I put patient's in a boot initially but adherence is questionable. I see a lot of peroneal tendonitis when the weathers good in my patient population, maybe because they built like 30 pickleball courts a few blocks down.

I know people still inject them, I don't like the idea of that but is anyone doing that?

Do ya'll prefer Meloxicam vs Celecoxib

Boot and medrol dose pack. Hand those out like candy. Tendonitis needs to chill out. Don't move it. Then also meloxicam.

 

[air bud]

This is the most useful post on this entire forum in a while. Stuff we actually deal with on the daily.

What are ya'll doing for tendonitis, I put patient's in a boot initially but adherence is questionable. I see a lot of peroneal tendonitis when the weathers good in my patient population, maybe because they built like 30 pickleball courts a few blocks down.

I know people still inject them, I don't like the idea of that but is anyone doing that?

Do ya'll prefer Meloxicam vs Celecoxib

Boot and medrol dose pack. Hand those out like candy. Tendonitis needs to chill out. Don't move it

Steroid injection. Home exercises vs formal PT. Depending on etiology (acute injury/overuse vs biomechanic foot issue) sometimes powersteps or other pre-fab insert recommendation for the medium to long term.

Have never injected a tendon. Probably could get away with it. I don't have the cojones like dtrack.

 

[Hybrocure]

152 posts in 5 days. I have a feeling this is going to be a wealth of info going forward lol

 

[Hybrocure]

Boot and medrol dose pack. Hand those out like candy. Tendonitis needs to chill out. Don't move it

Have never injected a tendon. Probably could get away with it. I don't have the cojones like dtrack.

The whole “ah I don’t inject into the tendon just the sheath” thing people say is so unrealistic. Like yeah you’re so tactile you can feel the difference

 

[air bud]

152 posts in 5 days. I have a feeling this is going to be a wealth of info going forward lol

Nails nails nails Dremel tolycen nails

 

[DYK343]

Nails nails nails Dremel tolycen nails

tolycen has officially entered the thread

 

[Hybrocure]

Nails nails nails Dremel tolycen nails

Tolycen is a mustache dog whistle

 

[Weirdy]

Another TFP question- labs we use don't do fungal staining.
Only culture.
Cultures come back negative most of the time even if it looks/smells/tastes like onycho.
How are you guys testing if you are?
Am I just looking up the wrong lab code?

 

[deleted1162946]

152 posts in 5 days. I have a feeling this is going to be a wealth of info going forward lol

We all have questions about random things especially us new in practice. Smart posters/good surgeons on here. Great resource. I hope it doesn’t take away from the meme thread though. If anything we’ll probably get juicier memes

 

[Homo sapien]

Another TFP question- labs we use don't do fungal staining.
Only culture.
Cultures come back negative most of the time even if it looks/smells/tastes like onycho.
How are you guys testing if you are?
Am I just looking up the wrong lab code?

I don't test. If it looks/smells/tastes then I treat it like fungus. I also ask the patients any questions about trauma, chemo/radiation. If the nail is thick green and black I usually just remove it. I don't have time to waste ****ing around with topicals and promises that maybe the nail will get better or whatever.

If it's not fully destroyed and no trauma/radio history, try lamisil

If it's partially destroyed with trauma, temp removal with the caveat it may not grow normal

If it's fully destroyed I remove it, most times permanently

 

[Adam Smasher]

In lectures, Warren Joseph has talked about malpractice cases where the defendant loses because they haven't confirmed the dx. Because he wasn't consulting for any path labs at the time, I've always been inclined to believe it. However I have been unable to find any plaintiff verdicts backing this claim up.

The way I look at it, patients have a right to know, they pay their insurance premiums, and I'm not not going to order a test just to save the insurance company money. This isn't take a z-pack empirically because of an ill-advised liaison with someone you met at a bar. This is a 3 month course of a drug so may as well know what we're treating.

@Weirdy you may need to have your institution send the specimen out to a reference lab, in which case I understand why you would find this to be too much work. Otherwise, it's not hard to order the test. Tick off boxes on a requisition form, medical assist does rest, pt enrolls in our online patient portal to see results. I send them a message via portal when results come in, rx as appropriate.

 

[Hybrocure]

I biopsy all fungal nail patients. It’s not in house and I don’t make anything on it. I send it out. But I’ve gotten too many letters from insurances wanting proof before certain topicals.

And in the case of terbinafine, why put them on an unnecessary 90 day course for something that may not be fungus but trauma related

 

[air bud]

I don't test. If it looks/smells/tastes then I treat it like fungus. I also ask the patients any questions about trauma, chemo/radiation. If the nail is thick green and black I usually just remove it. I don't have time to waste ****ing around with topicals and promises that maybe the nail will get better or whatever.

If it's not fully destroyed and no trauma/radio history, try lamisil

If it's partially destroyed with trauma, temp removal with the caveat it may not grow normal

If it's fully destroyed I remove it, most times permanently

Toenails are unnecessary.

 

[Homo sapien]

I biopsy all fungal nail patients. It’s not in house and I don’t make anything on it. I send it out. But I’ve gotten too many letters from insurances wanting proof before certain topicals.

And in the case of terbinafine, why put them on an unnecessary 90 day course for something that may not be fungus but trauma related

Yes. I think we should always get enough of a history to try to distinguish between fungus, trauma, or combo

 

[Bluecollarmed]

I'll KOH debris/nail clippings if I can't ascertain a reason for the dystrophy prior to starting an oral course. As an employed boot at a hospital that does it right away, it's not much extra for me to confirm it prior to starting a 3 month dose. Keeps the hospital happy that I'm contributing to other departments and it's a CYA thing on my end, especially in a very rare instance they have a complication from the medication.

 

[deleted1162946]

You guys ever had a patient that is irate when it’s not fungal but just dystrophic and they can’t have it treated? Only solution at that point is to offer a permanent nail avulsion. Some patients are crazy. It’s always the most mild discolored nail too.

I’ll biopsy if it is one isolated nail, previous trauma, failed anti fungals in the past. I’m not biopsying everyone.

 

[Homo sapien]

You guys ever had a patient that is irate when it’s not fungal but just dystrophic and they can’t have it treated? Only solution at that point is to offer a permanent nail avulsion. Some patients are crazy. It’s always the most mild discolored nail too.

I’ll biopsy if it is one isolated nail, previous trauma, failed anti fungals in the past. I’m not biopsying everyone.

I do and I explain to them that the nail is scarred, much like people with burns get skin scars/discoloration/changes and that's just it. They can get it avulsed and paint a fake nail or something but none of this is magic. I don't biopsy that. Don't bend over for these irate dinguses

 

[air bud]

I do and I explain to them that the nail is scarred, much like people with burns get skin scars/discoloration/changes and that's just it. They can get it avulsed and paint a fake nail or something but none of this is magic. I don't biopsy that. Don't bend over for these irate dinguses

You can live with it or I can remove it. You choose.

 

[DYK343]

If they want nails treated I dont test KOH or culture.

Straight to oral terbinafine. I do check liver enzymes once if not recently tested (already discussed on here I think).

It works most of the time or at least improves the nails.

Some nails obviously too far gone and then its live with it or matrixectomy.

 

[Boba Foot]

Yeah I drained a mucoid cyst in office recently. Felt stupid after. First, I couldn’t really collect any cyst like fluid in my needle. Second, even when done in a sterile environment I feel like it’s risky. could easily seed bacteria into the joint as it’s connected through a channel to the joint fluid.and it’s definitely going to reoccur. From now on I’ll just offer to cut it out if symptomatic

Mucoid cysts can be a goldmine. I always take them to the OR. Code for soft tissue mass removal, arthroplasty of DIPJ to prevent recurrence and then bilobed flap. I’ve had them pay more than a Lapidus.

You guys ever had a patient that is irate when it’s not fungal but just dystrophic and they can’t have it treated? Only solution at that point is to offer a permanent nail avulsion. Some patients are crazy. It’s always the most mild discolored nail too.

I’ll biopsy if it is one isolated nail, previous trauma, failed anti fungals in the past. I’m not biopsying everyone.

Yes, I’ve had two younger women who have gotten very upset when I told them their nails are dystrophic and not fungal and there ain’t **** anyone can do for it but complete matrixectomy or live with it. One was apoplectic and I had to refer to another doctor in our group so they could tell her the same thing.

 

[Adam Smasher]

Mucoid cysts can be a goldmine. I always take them to the OR. Code for soft tissue mass removal, arthroplasty of DIPJ to prevent recurrence and then bilobed flap. I’ve had them pay more than a Lapidus.

On the one hand, this seems like an upcode. At the very least you shouldnt bill excision of [subcutaneous] soft tissue mass when taking out a cutaneous cyst. On the other hand, upcoding like this is a very TFP thing to do. Might not be appropriate IRL but is appropriate content for this thread

Yes, I’ve had two younger women who have gotten very upset when I told them their nails are dystrophic and not fungal

I sell patients like this Bako's 40% urea nail gel. Either they buy it and the nail gets a little better and I've created a revenue stream, or they don't buy it but at least lose their attitude

 

[Homo sapien]

On the one hand, this seems like an upcode. At the very least you shouldnt bill excision of [subcutaneous] soft tissue mass when taking out a cutaneous cyst. On the other hand, upcoding like this is a very TFP thing to do. Might not be appropriate IRL but is appropriate content for this thread

I sell patients like this Bako's 40% urea nail gel. Either they buy it and the nail gets a little better and I've created a revenue stream, or they don't buy it but at least lose their attitude

I'd much rather tell them to **** off, that revenue stream ain't worth the hassle

 

[air bud]

Mucoid cysts can be a goldmine. I always take them to the OR. Code for soft tissue mass removal, arthroplasty of DIPJ to prevent recurrence and then bilobed flap. I’ve had them pay more than a Lapidus.

Yes, I’ve had two younger women who have gotten very upset when I told them their nails are dystrophic and not fungal and there ain’t **** anyone can do for it but complete matrixectomy or live with it. One was apoplectic and I had to refer to another doctor in our group so they could tell her the same thing.

Yeah I don't see how you bill that. I would bill an arthroplasty of toe and that's it. Maybe I am under. You are over.

 

[deleted1162946]

Anyone billing toe fillet flaps?

 

[air bud]

Anyone billing toe fillet flaps?

Yes when you debone the toe and use it to cover something. That is an easily abused code.

 

[HaimFeldman]

Boot and medrol dose pack. Hand those out like candy. Tendonitis needs to chill out. Don't move it

I had a patient's primary doc get upset with me for giving a medrol dose pack to one of his geriatric patient's with some achilles tendinosis that he referred to me for. Apparently I significantly increased her risk of DVT.
Coincidentally, this doctor also insists that none of his patient's go on oral terbinafine.

 

[Homo sapien]

I had a patient's primary doc get upset with me for giving a medrol dose pack to one of his geriatric patient's with some achilles tendinosis that he referred to me for. Apparently I significantly increased her risk of DVT.
Coincidentally, this doctor also insists that none of his patient's go on oral terbinafine.

Is this doctor old.

 

[HaimFeldman]

Is this doctor old.

Surprisingly no... at least I don't think. He looks mid 40s at the oldest.

 

[DYK343]

Anyone billing toe fillet flaps?

A few a year. It pays well but I dont think its really that useful.

 

[Carbon13]

WARTS WARTS WARTS

My Cantharone source is temporarily dried up due to chemical shortage.
I see at least 5-6 college kids a week with these things.
I'm considering using TCA 80% for the moment. (GILL)

Anyone have experience with this? Application method ?

 

[deleted1162946]

WARTS WARTS WARTS

My Cantharone source is temporarily dried up due to chemical shortage.
I see at least 5-6 college kids a week with these things.
I'm considering using TCA 80% for the moment. (GILL)

Anyone have experience with this? Application method ?

I apply TCA 80%. The bottle it comes in is like an eyedrop bottle. I put five or six drops on the end of a cotton tip applicator and then apply it. It doesn’t do much but I may be applying it wrong. I think silver nitrate sticks are better

 

[heybrother]

WARTS WARTS WARTS

My Cantharone source is temporarily dried up due to chemical shortage.
I see at least 5-6 college kids a week with these things.
I'm considering using TCA 80% for the moment. (GILL)

Anyone have experience with this? Application method ?

I put some on a person recently who didn't respond to cantharone. Will be curious to see how it goes.

Did ya'll know there's a Reddit dedicated to HPV which can be treated with trichloroacetic acid.

 

[deleted1162946]

I put some on a person recently who didn't respond to cantharone. Will be curious to see how it goes.

Did ya'll know there's a Reddit dedicated to HPV which can be treated with trichloroacetic acid.

View attachment 400861
View attachment 400862

Funny enough immiquod is also what I have people do for warts at home. 3 times a week and occlude with duct tape. Works really well in some and then not in others. Very weird

 

[heybrother]

Funny enough immiquod is also what I have people do for warts at home. 3 times a week and occlude with duct tape. Works really well in some and then not in others. Very weird

I've used 5-FU and Aldara to - as you say - mixed effect. Tried adapalene once a few years ago - it sadly failed. Was funny because there's an article on Adapalene in an Indian journal where it shows 100% success.

 

[Hybrocure]

People make warts too complicated. Never used Cantharone. It’s a treatment pushed by Big Beetle. Plenty of alternatives.

 

[deleted1162946]

People make warts too complicated. Never used Cantharone. It’s a treatment pushed by Big Beetle. Plenty of alternatives.

It was by far the best treatment. May it rest in peace…

 

[Feli]

People make warts too complicated. Never used Cantharone. It’s a treatment pushed by Big Beetle. Plenty of alternatives.

Yep, proper debride + salicylic for 98%.

Canth can be used for 2% (then back to salic)... then surg excision for the 1%.

 

[MicroPod]

5-FU has worked pretty well so far. Only had a few though

 

[Hybrocure]

Yep, proper debride + salicylic for 98%.

Canth can be used for 2% (then back to salic)... then surg excision for the 1%.

Exactly what I do

 

[Boba Foot]

On the one hand, this seems like an upcode. At the very least you shouldnt bill excision of [subcutaneous] soft tissue mass when taking out a cutaneous cyst. On the other hand, upcoding like this is a very TFP thing to do. Might not be appropriate IRL but is appropriate content for this thread

The cyst communicates with the joint. How is that cutaneous? Sorry you don’t like money.

 

[Hybrocure]

The cyst communicates with the joint. How is that cutaneous? Sorry you don’t like money.

I understand billing the cyst and the excision of bone.

The flap is the iffy part imo. Isn’t that just closing skin? Taking out a mucoid w a dip arthroplasty is just an elliptical incision

 

[air bud]

5-FU has worked pretty well so far. Only had a few though

Switched to 5FU at dyk343 and Feli recommendations....was cantharidin before.

 

[air bud]

Does anyone have a preference for mustache wax?

 

[Adam Smasher]

Does anyone have a preference for mustache wax?

Every Man Jack Beard Butter, keeps things smooth and luxurious. Women want you, associates want to be you.

 

[Homo sapien]

I've used 5-FU and Aldara to - as you say - mixed effect. Tried adapalene once a few years ago - it sadly failed. Was funny because there's an article on Adapalene in an Indian journal where it shows 100% success.

I use adapalene but I always do deep debridement first once. It works for me. But it needs to be able to penetrate, not just on top

 

[deleted1162946]

is Nuzyra legit? It’s a pain in the ass to order when I can just do doxycycline. Feels like a scam.

 

[Adam Smasher]

is Nuzyra legit? It’s a pain in the ass to order when I can just do doxycycline. Feels like a scam.

Does it do what it needs you to do? Yes

Is it cost-effective? For $7000/rx, I'll leave it to you to judge.

 

[deleted1162946]

Does it do what it needs you to do? Yes

Is it cost-effective? For $7000/rx, I'll leave it to you to judge.

It’s really $7,000? My only patient I ever placed on it went to their “patience assistance” and got it paid for

I think I’ll stick to doxy.., not going to let someone else/a company manipulate me into getting rich off an abx. Ridiculous

 

[heybrother]

I use adapalene but I always do deep debridement first once. It works for me. But it needs to be able to penetrate, not just on top

I'll presumably try it again in the future. The kid I used it on failed everything so I don't know why adapalene would be any different. The wart microwave people would have us believe/know that there are HPV variants that are much more difficult to treat - perhaps that's an explanation for why some people are so treatment resistant.

is Nuzyra legit? It’s a pain in the ass to order when I can just do doxycycline. Feels like a scam.

I just wrote my first prescription for an unpleasant diabetic wound. Guess I'll see what I'm in for. I swear the rep wants me to write it for ingrown toenails. 👎to that.

Having reps pushing antibiotics feels really strange compared to being around Infectious Disease doctors pushing stewardship.