MYAEKEL
Contributor
How would you code the following op note:
PREOP DIAGNOSIS: Carpal tunnel syndrome left wrist with synovitis of the left wrist
POST OP DIAGNOSIS: Carpal tunnel syndrome left wrist with synovitis of the left wrist
PROCEDURE:
1. Endoscopic release transverse carpal ligament.
2. Arthrotomy and synovectomy of the wrist.
DESCRIPTION OF THE PROCEDURE: The patient was placed in the supine position under a regional anesthetic and a well-padded tourniquet placed about the upper arm, inflated to 250 mmHg for less than an hour. A carfully placed anterior incision carried transversely across the base of the wrist down to the flexor retinaculum. This was then identified, split along its fibers and retracted anteriorly where subligamentous dissection was then performed with a dissector and sound. The endoscopic construct was then placed into this same space in the subligamentous region and the fibers of the transverse carpal ligament identified. They were then released with the endoscopic construct with direct visualization. A second pass confirmed this. The wound was copiously irrigated. Retractors were then used to retract the carpal canal structures radially and arthrotomy and synovectomy of the wrist performed. The instruments were then removed. A bulky dressing applied.
The patient was taken to the recovery room having tolerated the procedure quite nicely.
Thanks in advance!
PREOP DIAGNOSIS: Carpal tunnel syndrome left wrist with synovitis of the left wrist
POST OP DIAGNOSIS: Carpal tunnel syndrome left wrist with synovitis of the left wrist
PROCEDURE:
1. Endoscopic release transverse carpal ligament.
2. Arthrotomy and synovectomy of the wrist.
DESCRIPTION OF THE PROCEDURE: The patient was placed in the supine position under a regional anesthetic and a well-padded tourniquet placed about the upper arm, inflated to 250 mmHg for less than an hour. A carfully placed anterior incision carried transversely across the base of the wrist down to the flexor retinaculum. This was then identified, split along its fibers and retracted anteriorly where subligamentous dissection was then performed with a dissector and sound. The endoscopic construct was then placed into this same space in the subligamentous region and the fibers of the transverse carpal ligament identified. They were then released with the endoscopic construct with direct visualization. A second pass confirmed this. The wound was copiously irrigated. Retractors were then used to retract the carpal canal structures radially and arthrotomy and synovectomy of the wrist performed. The instruments were then removed. A bulky dressing applied.
The patient was taken to the recovery room having tolerated the procedure quite nicely.
Thanks in advance!