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A1 Pulley Release Medical Transcription Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Left trigger thumb.

POSTOPERATIVE DIAGNOSIS:
Left trigger thumb.

OPERATION PERFORMED:
A1 pulley release, left trigger thumb.

SURGEON:  John Doe, MD

ANESTHESIA:
Local.

ESTIMATED BLOOD LOSS:
Minimal.

COMPLICATIONS:
None.

INDICATION FOR OPERATION:
The patient is a (XX)-year-old male who has been complaining of pain in the left thumb for the past several months.  The patient was diagnosed with a left trigger thumb and had failed nonoperative management.  The patient had been complaining of locking of the left thumb. The patient wished to proceed with operative intervention.  All risks and benefits of the procedure were discussed in detail with the patient and informed consent was obtained.

DESCRIPTION OF OPERATION:
The patient was brought to the operating room and placed on the table in the supine position.  One gram of Ancef was given in the preoperative holding area.  Local anesthetic in the form of Marcaine was injected in the left thumb base, around the A1 pulley.  The left upper extremity was then prepped and draped in the regular sterile routine fashion.  A tourniquet was placed on the left forearm prior to draping.  Esmarch was used for exsanguination and the tourniquet was inflated to 275 mmHg.  A transverse incision over the proximal crease of the left thumb, over the A1 pulley, was performed.  The ulnar digital nerve of the thumb was identified and protected.  The A1 pulley was identified and was incised with an 11 blade.  All adhesions were taken down around the FPL tendon.  The tourniquet at this point was deflated and hemostasis was secured.  The patient was asked to move the thumb and was able to flex the thumb without any triggering.  The wound was irrigated copiously with normal saline and the skin was closed with 5-0 nylon.  A dressing was applied in the form of Adaptic, 4 x 4 and Coban.  The patient tolerated the procedure well and was taken to the recovery room in stable condition without any complications.