- Preoperative Diagnoses 1 Blunt Trauma With Paint Ball Right Cye 2 Hyphema Right Eye Secondary To 1 3 Recurrent 1 (79.75 KiB) Viewed 45 times
- Preoperative Diagnoses 1 Blunt Trauma With Paint Ball Right Cye 2 Hyphema Right Eye Secondary To 1 3 Recurrent 2 (12.73 KiB) Viewed 45 times
- Preoperative Diagnoses 1 Blunt Trauma With Paint Ball Right Cye 2 Hyphema Right Eye Secondary To 1 3 Recurrent 3 (28.21 KiB) Viewed 45 times
PREOPERATIVE DIAGNOSES: 1. Blunt trauma with paint ball, right cye. 2. Hyphema, right eye, secondary to #1. 3. Recurrent hyphema, right eye, secondary to #1 4. Corneal staining, right eye, secondary to #1 5. Increased Intraocular pressure, right eye, secondary to #l. 6. Dense cataract, right eye, secondary to #1 POSTOPERATIVE DIAGNOSIS: Same. PROCEDURE PERFORMED: Irrigation and aspiration of hyphema and blood clot anterior chamber, right eye. ANESTHESIA: General endotracheal anesthesia. INDICATION: This 14-year-old white male has had persistent problems since he was hit with a paint ball in his right eye 2 weeks ago. It has not resolved. It has continued to bleed and now it has formed a huge clot. Because of the increase in pain and obvious corneal staining, it was elected to irrigate the clot at this time. No guarantees were made to the mother for vision. DESCRIPTION OF PROCEDURE: After the patient was prepped and draped in the usual sterile fashion for ophthalmic surgery under general endotracheal anesthesia, a wire lid speculum was used to separate the lids of the right eye. The Super knife was then used in the limbal area to make a 2-mm-wide incision at the 8-o'clock meridian, and the chamber was filled with BSS Plus. Using the Simcoe I&A apparatus, gentle suction, and a push- pull method, the clot was removed and the blood was irrigated. There was no damage done to the lens surface or to the iris and the pupil remained round. Healon was used to help dissolve the clot and make it easier for aspiration. At the end of the procedure, all the Healon and blood clot was removed and the pupil remained round. There was a dense cataract well on its way to hypermaturity already present, but no evidence of any vitreous or subluxation of the lens. The wound was closed with a 10-0 nylon suture, and the knot was buried. Healon was then placed over the cornea because the cornea showed some irregularity secondary to the paint ball explosion. Solu-Medrol was injected inferiorly Sub-Tenon's. Atropine 1% was placed in
APPENDIX A. Reports the eye and Maxitrol ointment and a Telfa pad, patch, and shield applied. The patient was sent to the Recovery Room. There were no complications.
2. Explain why you chose the ICD-9/ICD-10 and CPT code for each answer. 3. Focus on why you chose the answer and the function of each body system or body part. 4. The purpose of this discussion is to think about the case and add a meaningful, useful response.