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Exam (elaborations)

AAPC - Chapter 15 Practical Applications

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ANESTHESIA: Laryngeal mask anesthesia. PREOPERATIVE DIAGNOSIS: Retinal detachment, right eye. POSTOPERATIVE DIAGNOSIS: Retinal detachment, right eye.(The postoperative diagnosis is used for coding.) PROCEDURE: Scleral buckle, cryoretinopexy, drainage of subretinal fluid, C3F8 gas in the right eye. PROCEDURE: After the patient had received adequate laryngeal mask anesthesia, he was prepped and draped in usual sterile fashion. A wire lid speculum was placed in the right eye. A limbal peritomy was done for 360 degrees using 0.12 forceps and Westcott scissors. Each of the intramuscular quadrants was dissected using Aebli scissors. The muscles were isolated using a Gass muscle hook with an 0 silk suture attached to it. The patient had an inspection of the intramuscular quadrants and there was no evidence of any anomalous vortex veins or thin sclera. The patient had an examination of the retina using an indirect ophthalmoscope and he was noted to have 3 tears in the temporal and inferotemporal quadrant and 2 tears in the superior temporal quadrant. (Exam reveals the location of the tears.) These were treated with cryoretinopexy.(Cryoretinopexy is the use of intense cold to close

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