腕管综合征手术记录模板范文

腕管综合征手术记录模板范文英文回答：
Title: Surgical Record Template for Carpal Tunnel Syndrome.
Introduction:
Carpal tunnel syndrome (CTS) is a common condition characterized by the compression of the median nerve in the wrist. When conservative treatments fail to provide relief, surgical intervention may be necessary. This surgical record template aims to provide a comprehensive documentation of the procedure performed for CTS.
Patient Information:
Name: [Patient's Name]
Age: [Patient's Age]
Gender: [Patient's Gender]
Medical History: [Brief summary of relevant medical history]
Procedure:
Date: [Date of Surgery]
Surgeon: [Name of Surgeon]
Anesthesia: [Type of Anesthesia]
Preoperative Assessment:
The patient was evaluated preoperatively to confirm the diagnosis of CTS through a combination of physical examination, nerve conduction studies, and medical imaging. The severity of symptoms and functional limitations were assessed using validated scales such as the Boston Carpal Tunnel Questionnaire.
Surgical Technique:
A standard open carpal tunnel release (CTR) procedure was performed. The patient was placed in a supine position with the affected arm abducted and externally rotated. A tourniquet was applied proximal to the surgical site. A longitudinal incision was made over the flexor retinaculum, extending from the distal wrist crease to the proximal palm. Blunt dissection was performed to expose the transverse carpal ligament. The ligament was then divided, releasing
the pressure on the median nerve. Hemostasis was achieved, and the wound was closed in layers using absorbable sutures.
Intraoperative Findings:
During the surgery, the following findings were noted:
Thickening and fibrosis of the transverse carpal ligament.
Compression and flattening of the median nerve.
Absence of any other significant abnormalities.
Postoperative Care:
The patient was instructed to elevate the hand and keep it in a sling for the first few days following surgery. Pain management was provided through the administration of analgesics, and the patient was advised to perform gentle range of motion exercises. A follow-up appointment was scheduled for wound evaluation, suture removal, and further assessment of symptoms.
Complications:
No immediate complications were encountered during the surgical procedure. However, potential complications such as infection, nerve injury, or scar formation were discussed with the patient during the consent process.
Conclusion:
The surgical procedure for carpal tunnel syndrome was performed without any complications. The patient tolerated the procedure well and was discharged with appropriate postoperative instructions. Follow-up appointments will be scheduled to monitor the patient's progress and ensure optimal recovery.
中文回答：
标题，腕管综合征手术记录模板范文。

简介：
腕管综合征（CTS）是一种常见疾病，其特点是手腕处的橈骨神
经受到压迫。

当保守治疗无法缓解症状时，可能需要进行手术干预。

这份手术记录模板旨在提供对CTS手术过程的全面记录。

患者信息：
姓名，[患者姓名]
年龄，[患者年龄]
性别，[患者性别]
病史，[相关病史简要总结]
手术过程：
日期，[手术日期]
外科医生，[外科医生姓名]
麻醉，[麻醉类型]
术前评估：
术前对患者进行评估，通过体格检查、神经传导研究和医学影像学等方法确认CTS的诊断。

使用波士顿腕管综合征问卷等经过验证的评估量表评估症状的严重程度和功能限制。

手术技术：
进行了标准的开放性腕管放松术（CTR）手术。

患者取仰卧位，
患手外展和外旋。

手术部位上方应用止血带。

沿着掌侧腕横韧带切
口做纵行切口，从远端腕纹延伸到近端手掌。

进行钝性解剖，暴露
横向腕韧带。

然后切断韧带，减轻对橈骨神经的压迫。

止血后，采
用可吸收缝线逐层缝合创面。

术中发现：
手术过程中观察到以下情况：
横向腕韧带增厚和纤维化。

橈骨神经受压扁平。

未发现其他重要异常。

术后护理：
术后患者被告知在手术后的前几天内提高手部并用三角巾固定。

通过使用镇痛药进行疼痛管理，并建议患者进行轻柔的活动范围锻炼。

预约随访以评估创面情况、拆线和进一步评估症状。

并发症：
手术过程中没有发生明显并发症。

然而，在同意过程中已与患者讨论了潜在的并发症，如感染、神经损伤或瘢痕形成。

结论：
腕管综合征手术过程顺利进行，没有出现并发症。

患者对手术耐受良好，并获得了适当的术后指导。

随访预约将安排以监测患者的恢复情况并确保最佳康复效果。