LOCATION: Outpatient, Hospital PATIENT: Fanny Wilder SURGEON: John Hodgson, M.D. PREOPERATIVE DIAGNOSIS: Left carpal tunnel syndrome. POSTOPERATIVE DIAGNOSIS: Same. PROCEDURE PERFORMED: Carpal tunnel released, left wrist. ANESTHESIA: Regional. INDICATIONS: Patient has long history of numbness, tingling and pain from the wrist into the thumb of the left hand. Patient has used immobilizer with minimal effectiveness. Risks and benefits were discussed, she is aware of possible reoccurrence of symptoms. The procedure was explained and her questions were answered and she elects to proceed at this time. PROCEDURE: After a satisfactory level of regional anesthesia, the extremity was addressed once it had been sterilely prepped and draped. Throughout the procedure the patient needed some focal augmentation for sharp pain characteristics at the level of the skin most distally about the skin wound. Sharp dissection was conducted down to the palmaris fascia. We identified the deep transverse ligament. In a blunt manner, we undermined this, and with use of a Freer interposing between deep transverse carpal ligament and the medial nerve, sharply dissected over the Freer, releasing the impinging structures about the carpal canal. The probe palpation, the tendinous structures, and the floor of the carpal canal were otherwise unremarkable. She has at this time an exiting thenar motor branch, which was not obscured. There is an hourglass deformity of the median nerve as noted. At completion of this the wound was irrigated, followed by closure of the dermal planes and application of a splint. The patient tolerated the procedure well and was transported to the recovery room in a stable manner.
ICD -10 CM code is the tenth version of international classification of disease and is used by the healthcare workers to code a disease
CPT code is the current procedural terminology ,which is also used by the healthcare workers to code a procedure
ICD -10-CM code for left carpel tunnel syndrome is G56.02
CPT code for carpel tunnel released is 64721
LOCATION: Outpatient, Hospital PATIENT: Fanny Wilder SURGEON: John Hodgson, M.D. PREOPERATIVE DIAGNOSIS: Left carpal tunnel syndrome....
LOCATION: Inpatient, Hospital PATIENT: Karla Stevens SURGEON: John Hodgson, M.D. PREOPERATIVE DIAGNOSES: 1. Spinal stenosis, without neurogenic claudication. 2. Spondylolisthesis, L4-L5. 3. Right radicular pain L5 root. INDICATIONS: Karla is a 52-year-old woman who is a baker and stands on her feet for many hours a day. She was diagnosed with spinal stenosis and spondylolisthesis and continues to have low back pain. She understands the risks and potential complications and problems that may occur from the surgery and wishes to...
LOCATION: Outpatient, Hospital PATIENT: Shelby Winston SURGEON: Larry P. Friendly, M.D. PREOPERATIVE DIAGNOSIS: Recurrent right inguinal hernia. POSTOPERATIVE DIAGNOSIS: Same. PROCEDURES PERFORMED: Repair of recurrent right inguinal hernia. HISTORY: This is an 80-year-old female who has previously undergone a right inguinal hernia repair performed earlier this year. The repair was a type repair, and she, subsequently, returned with complaints of a new bulge in the right groin. An ultrasound was performed which demonstrated evidence of a right inguinal hernia. She...
PATIENT: Andy Hall SURGEON: Gary Sanchez, M.D. PREOPERATIVE DIAGNOSES: Right carotid stenosis POSTOPERATIVE DIAGNOSIS: Same. PROCEDURE PERFORMED: Right carotid thromboendarterectomy. This patient was monitored with EEG. There were some depressions when we clamped, but this returned to normal after re-establishing circulation. ANESTHESIA: General DESCRIPTION OF PROCEDURE: Under general anesthesia, the patient’s right side of the neck was prepped and draped in the usual manner. An incision was made across the medial border of the sternocleidomastoid. The platysma was divided. The...
LOCATION: Outpatient, Hospital PATIENT: Kaitlyn Carlton SURGEON: Loren White, M.D. ANESTHESIA: CRNA is Karen Demers PREOPERATIVE DIAGNOSIS: Epiphora, both eyes Nasolacrimal duct obstruction, both eyes POSTOPERATIVE DIAGNOSIS: Same. PROCEDURE PERFORMED: Nasolacrimal duct probing, both eyes ANESTHESIA: General INDICATIONS: This healthy 3-year-old toddler was referred after an allergy workup to investigate her chronic otitis media, PE tubes times two, and the chronic epiphora that she has had in both eyes. The mother was counselled as to the success of probing at...
LOCATION: Inpatient, Hospital PATIENT: Charlene Tipton SURGEON: Loren White, M.D. PRE/POSTOPERATIVE DIAGNOSIS: Right breast mass. PROCEDURE(S) PERFORMED: Right breast open biopsy. ANESTHESIA: General endotracheal. INDICATIONS: Charlene is a 66-year-old female who presented with a palpable right breast mass. A biopsy was done which showed atypical cells and was felt to be suspicious for cancer. She also had a highly suspicious lesion on ultrasound in the same area. An open biopsy was recommended. Possible definitive treatment with simple mastectomy was also...
Gary Sanchez, M.D. PREOPERATIVE DIAGNOSIS: Histiocytic tumor of the right shoulder Indications: This patient is a 62-year-old gentleman that was diagnosed with a histiocytic tumor of the right shoulder and requested surgical intervention. POSTOPERATIVE DIAGNOSIS: Same PROCEDURE PERFORMED: Excision of plexiform fibrous histiocytic tumor of the right shoulder. ANESTHESIA: General endotracheal with approximately 20 cc of tumescent solution prepared by adding to 1 L of Ringer's lactate, 25 cc 2% Xylocaine, 1 cc of 1:100,000 epinephrine, and 3 cc of...
LOCATION: Inpatient, Hospital PATIENT: Thomas Wilder PHYSICIAN: Loren White, M.D. ANESTHESIOLOGIST: CRNA is Karen Demers PREOPERATIVE DIAGNOSIS: 25% body surface area burns on face, posterior neck, trunk, bilateral upper extremities, hands, left foot and ankle. The total body surface area addressed was 15% which were third degree burns. POSTOPERATIVE DIAGNOSIS: Same. PROCEDURES: 1. Split-thickness skin graft, left upper back 14 x 6 cm. 2. Sheath split-thickness skin graft, left ankle 6 x 2 cm. ANESTHESIA: General. INDICATIONS: This 3-year-old was...
LOCATION: Inpatient, Hospital PATIENT: Thomas Wilder PHYSICIAN: Loren White, M.D. ANESTHESIOLOGIST: CRNA is Karen Demers PREOPERATIVE DIAGNOSIS: 25% body surface area burns on face, posterior neck, trunk, bilateral upper extremities, hands, left foot and ankle. The total body surface area addressed was 15% which were third degree burns. POSTOPERATIVE DIAGNOSIS: Same. PROCEDURES: 1. Split-thickness skin graft, left upper back 14 x 6 cm. 2. Sheath split-thickness skin graft, left ankle 6 x 2 cm. ANESTHESIA: General. INDICATIONS: This 3-year-old was...
PREOPERATIVE DIAGNOSIS: Left inguinal hernia. POSTOPERATIVE DIAGNOSIS: Large left inguinal hernia, direct. PROCEDURE: Repair of large direct left inguinal hernia with Prolene Hernia System Mesh (PHS) and resection of lipoma of the spermatic cord. FINDINGS: Large direct left inguinal hernia and large lipoma of the spermatic cord. DESCRIPTION OF PROCEDURE: After routine preparation, the patient was prepped and draped under general anesthesia in supine position. The bladder was decompressed with a Foley catheter. An incision was made in the left...
PREOPERATIVE DIAGNOSIS: Left inguinal hernia. POSTOPERATIVE DIAGNOSIS: Large left inguinal hernia, direct. PROCEDURE: Repair of large direct left inguinal hernia with Prolene Hernia System Mesh (PHS) and resection of lipoma of the spermatic cord. FINDINGS: Large direct left inguinal hernia and large lipoma of the spermatic cord. DESCRIPTION OF PROCEDURE: After routine preparation, the patient was prepped and draped under general anesthesia in supine position. The bladder was decompressed with a Foley catheter. An incision was made in the left...