Coding

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  • Topic: Rotator cuff, Shoulder, Glenohumeral joint
  • Pages : 2 (335 words )
  • Download(s) : 85
  • Published : April 21, 2013
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LOCATION: Outpatient, Hospital

PATIENT: Stan Hope

SURGEON: Mohamad Almaz, MD

PREOPERATIVE DIAGNOSIS: Left shoulder pain and numbness, past shoulder injury POSTOPERATIVE DIAGNOSIS: Normal shoulder

PROCEDURE PERFORMED: Diagnostic arthroscopy, left shoulder

CLINICAL HISTORY: This is a 57-year-old with a l0-year-old rotator cuff tear injury to his left shoulder. The patient does heavy lifting for a living. For the past 6 months the patient has been experiencing pain in this shoulder with some numbness and tingling traveling down the arm. X-rays were normal. Decision was made to go in with an arthroscope to try and uncover a reason for this pain and numbness.

OPERATIVE REPORT: Under general anesthesia, the patient was laid in the beachchair position on the operating room table. The left shoulder was examined and found to be stable. There is full range of motion of this shoulder also. The extremity was then prepped and draped in the usual fashion . A standard posterior arthroscopic portal was created and the camera was introduced. First the back of the joint was inspected and this did not show any evidence of damage. The anterior ligament structures were normal. The biceps attachment and its transit through the joint were normal. Subscapularis was intact with no abnormality. Old scarring of the rotator cuff was noted. But all looked as it should. Nothing abnormal was seen. The camera was then removed out of the glenohumeral joint and placed in the subacromial space. There was excellent visualization of this area. No abnormalities could be identified and there was no evidence of any impingements. The camera was then removed from the subacromial space. The area was then infiltrated with Marcaine. The posterior portal was then closed with absorbable sutures and Steri-Strips, and a Mepore dressing was placed on it. The arm was then placed in a sling; the patient awakened and was placed on her hospital bed and taken to the recovery room in good condition....
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