Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Surgery
Sample Name: Carpal Tunnel Release - 7

Description: Right carpal tunnel syndrome. Right carpal tunnel release.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Right carpal tunnel syndrome.

POSTOPERATIVE DIAGNOSIS: Right carpal tunnel syndrome.

PROCEDURE PERFORMED: Right carpal tunnel release.

PROCEDURE NOTE: The right upper extremity was prepped and draped in the usual fashion. IV sedation was supplied by the anesthesiologist. A local block using 6 cc of 0.5% Marcaine was used at the transverse wrist crease using a 25 gauge needle, superficial to the transverse carpal ligament.

The upper extremity was exsanguinated with a 6 inch ace wrap.

Tourniquet time was less than 10 minutes at 250 mmHg.

An incision was used in line with the third web space just to the ulnar side of the thenar crease. It was carried sharply down to the transverse wrist crease. The transverse carpal ligament was identified and released under direct vision. Proximal to the transverse wrist crease it was released subcutaneously. During the entire procedure care was taken to avoid injury to the median nerve proper, the recurrent median, the palmar cutaneous branch, the ulnar neurovascular bundle and the superficial palmar arch. The nerve appeared to be mildly constricted. Closure was routine with running 5-0 nylon. A bulky hand dressing as well as a volar splint was applied and the patient was sent to the outpatient surgery area in good condition.

Keywords: surgery, superficial palmar arch, carpal tunnel release, carpal tunnel syndrome, transverse wrist crease, superficial, ligament,
NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. All names and dates have been changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or place or anything else to real world is purely incidental.
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Transcribed Medical Transcription Sample Reports and Examples