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Musculoskeletal System- Case 1 OPERATIVE REPORT LOCATION: Outpatient, Hospital PATIENT: Glory Ann Borden SURGEON: Mohomad Almaz, MD DIAGNOSIS: Right carpal tunnel syndrome PROCEDURE PERFORMED: Right

Musculoskeletal System- Case 1

OPERATIVE REPORT

LOCATION: Outpatient, Hospital

PATIENT: Glory Ann Borden

SURGEON: Mohomad Almaz, MD

DIAGNOSIS: Right carpal tunnel syndrome

PROCEDURE PERFORMED: Right carpal tunnel release

PROCEDURE: The patient was placed in the supine position on the operating room table, where her right hand and forearm were prepped with Betadine and draped in a sterile fashion. We infiltrated the thenar crease area with 1% Xylocaine, and once adequate anesthesia had been achieved, we exsanguinated the hand and forearm with an Esmarch bandage. We then created a longitudinal incision just at the ulnar aspect of the thenar crease and carried the dissection down through the subcutaneous tissue. We identified the transverse carpal ligament and incised this both proximally and distally until we were certain that it was completely released. We identified the median nerve and found that it was free. We did spread the soft tissues surrounding it gently.

We then released the tourniquet after 8 minutes of tourniquet time, and bleeding was controlled with pressure and also with electrocautery. We thoroughly irrigated the area with saline. We then closed the skin using 4-0 nylon suture, and a Xeroform dressing was applied under a small pressure dressing. She was taken from the operating room in good condition. She tolerated this very well.

What is the name of the physician you are coding for in Case-1?

What is the main term for the procedure found in Case-1?

Assign the CPT code for Case-1: _________

What modifier is used in Case-1: ___

What is the main term for the diagnosis reported in Case-1?

Assign the ICD-10-CM code for Case-1: _____________

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