EXAMPLE
Barry Tuch, M.D.
OPERATIVE REPORT
________________________________
ANESTHESIOLOGIST: Amitabh Mathur, M.D.
ANESTHESIA: IV lidocaine block.
PREOPERATIVE DIAGNOSES:
1.
Left carpal tunnel syndrome.
2.
Flexor tendonitis left thumb with trigger thumb.
POSTOPERATIVE DIAGNOSES:
1.
Left carpal tunnel syndrome.
2.
Flexor tendonitis left thumb with trigger thumb.
OPERATIVE PROCEDURE:
1. Release of carpal tunnel.
2. Release of left thumb trigger finger.
HISTORY AND PHYSICAL: The patient is a 55-year-old right hand
dominant female who has had numbness and tingling in her left
hand consistent with carpal tunnel syndrome for 15 years. In
addition, she has had triggering of her left thumb. Both
conditions have been unresponsive to conservative treatment and
are becoming progressively worse.
OPERATIVE PROCEDURE: The patient was given an IV lidocaine block
by Dr. Mathur. First, he exsanguinated the left arm with an
Esmarch bandage and then inflated a pneumatic tourniquet to 250
mmHg. He administered the IV lidocaine and then the left arm was
prepped sterilely and draped per the usual sterile manner. A
curved palmar skin incision was made over the carpal tunnel
extending minimally into the wrist area and forearm. This was
deepened by sharp and blunt dissection and bleeders were
coagulated with the Bovies encountered. The transverse carpal
ligament was incised in line with the skin incision revealing a
flattened median nerve beneath it. Complete release of the
transverse carpal ligament was performed so that there was no
further impingement on the median nerve. The wound was irrigated
with Bacitracin antibiotic solution. Part way through the
procedure it was necessary to infiltrate the wound edges with
0.25% plain Marcaine to aid in the anesthesia. The wound was then
closed with interrupted vertical mattress 3-0 Prolene suture.
The second part of the procedure was release of the trigger
thumb. A transverse incision was made over the volar NCP area in
the region of the A1 pulley. After the skin was incised, the rest
of the tissues were dissected by blunt dissection. The ulnar
digital nerve was visualized and it was retracted safely out of
the way. The A1 pulley was identified and was incised with a #11
blade. The thumb was flexed and extended, and there was no
catching or locking of the thumb and the flexor tendons moved
easily and without impingement in the area. This wound was
irrigated with Bacitracin antibiotic solution. The skin edges
were infiltrated with 0.25% plain Marcaine and then closed with
interrupted vertical mattress 3-0 Prolene suture. A sterile,
bulky, compressive dressing was applied. The arm was immobilized
in a short arm volar fiberglass splint with the wrist in slight
extension. The tourniquet was deflated after being up a total of
48 minutes and there prompt return of circulation distally. The
patient was transferred to the recovery room, awakened in
satisfactory condition.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: None.