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PATIENT: Patricia Ortez
PHYSICIAN: Harold Green, MD
PREOPERATIVE DIAGNOSIS: Left frozen shoulder.
POSTOPERATIVE DIAGNOSIS: Left frozen shoulder.
1. Arthroscopic debridement, left shoulder.
2. Joint manipulation, left shoulder.
CLINICAL HISTORY: This 52-year-old lady presented with a history of progressive pain and discomfort of her left shoulder. Evaluation confirmed evidence of a left frozen shoulder. After the risks and benefits of anesthesia and surgery were explained to the patient, the decision was made to undertake the procedure.
REPORT OF OPERATION: Under general anesthesia, the patient was laid in the beach-chair position on the operating room table. The left shoulder was prepped and draped in the usual fashion. A standard posterior arthroscopic portal was created, with the camera introduced into the back of the joint. We had excellent visualization. It was immediately apparent that there was substantial inflammation throughout the entirety of the joint. Using a switch stick technique, we created an anterior portal and brought in the 7-mm cannula from the front. With a 4.0 double-biter resector, the synovium was then debrided throughout the entirety of the rotator cuff over the surface of the biceps and the anterior ligamentous structures, as well as the inferior ligamentous structures. With this completed, the joint was then thoroughly irrigated to remove any blood. The articular surfaces were inspected and were found to be normal. The attachment of the biceps was normal, although it had been covered with synovium. Anterior ligamentum structures were free from the subscapularis. The joint was then infiltrated with 80 mg of Depo-Medrol and 12 cc of Marcaine. The instruments were removed. The arthroscopic portal was closed with absorbable sutures and Steri-Strips. The joint was then manipulated. Prior to manipulation, we had about 90 degrees of elevation passively. Postmanipulation evaluation was free up to 180 degrees, and external rotation in an abducted position was possible to 90 degrees, as was internal rotation. Extension was possible to 40 degrees, and adduction was possible to 50 degrees. The wounds were then dressed with Myopore dressing. The patient was then placed in a CryoCuff sling, awakened and placed on her hospital bed, and taken to the recovery room in good condition.
CPT Anesthesia Code?
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