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Carpal Tunnel Release Transcribed Sample Report / Example

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Severe bilateral carpal tunnel syndrome, postpartum.

POSTOPERATIVE DIAGNOSIS:
Severe bilateral carpal tunnel syndrome, postpartum.

OPERATION PERFORMED:
1.  Right carpal tunnel release.
2.  Left carpal tunnel release.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal.

ANESTHESIOLOGIST:  Jane Doe, MD

SPECIMENS:  None.

ESTIMATED BLOOD LOSS:  Minimal.

DESCRIPTION OF OPERATION:  The patient was advised preoperatively as to the nature of the problem and treatment options and elected to proceed. The patient was receiving intravenous ampicillin as previously ordered. She was taken to the operating room by the nursing staff where general endotracheal anesthesia was induced. Tourniquets were applied over both upper extremities. The right upper extremity was prepped and draped in the usual sterile fashion for upper extremity surgery. The hand and arm were elevated and exsanguinated and tourniquet inflated to 250 mmHg pressure. The hand and fingers were stabilized of the right hand. An incision was made in the proximal palm, up to but not across the wrist flexion crease. Bleeding points were cauterized with bipolar cautery. The superficial palmar fascial fibers were sharply divided, revealing the underlying carpal ligament which was completely divided. Care was taken to protect the adjacent neurovascular structures. The antebrachial fascia was divided under direct vision, again taking care to protect the adjacent neurovascular structures. The motor and sensory branches in the median nerve were demonstrated. The fat pad and vascular arch were visualized. The nerve was markedly hyperemic at the level of the carpal tunnel and edematous proximally and distally. The small adhesions between the median nerve in the undersurface, the radial side of the carpal ligament were gently taken down. Complete release was demonstrated. The anatomy was otherwise unremarkable. There were no palpable masses. The wound was thoroughly irrigated. The tourniquet was released. Hemostasis was secured with bipolar cautery. The soft tissues were infiltrated with 0.25% plain Marcaine. Once hemostasis was verified, the incision was then closed with interrupted 5-0 nylon sutures. A supportive sterile dressing was applied. A similar procedure was performed for the left upper extremity. Findings on the left side were similar. After completion of the surgery, the patient was successfully extubated. The patient was returned to the recovery area where stable vital signs were recorded. Needle and instrument counts were correct.

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