Duty Report

th
Friday April 3 2015

Ophtalmologist : dr. Afrisal H K, Sp.M(K)

Senior resident : dr. Andhika
Junior resident : dr. Rahman Kartiko

Patient Identity
Name : Mr. B
Age : 57th Years old

Major Complain: Blur right eye

10 day Hour before come to RSDK,

the patient say

many black dots floating point, flash

of light(-), Blur(-) ,go to local RS.
And get vitreolenta 4 times and
matovit 1 times

There was no changes on his right

eye. Then go to

RSDK

 RPD:
No Eye trauma before
DM + 10 years, no routine
control
RP Sos-Ek:
health insurance by BPJS

Visus

OD

OS

2/60

0,3

palpebr edema (-)

spasme (-)
a

edema (-) spasme

(-)

conjunc Khemosis (-)

tiva

Khemosis (-)

Kornea
COA

clear

clear

ACD enough, TE ACD enough, TE (-)

(-)

OD
iris
pupil

OS

Kripte (+)
Kripte (+)
Round, central,
Round, central,
reguler,
reguler,
diameter3mm, diameter3mm,
PR (+)
PR (+)
lensa
turbid uneven
turbid uneven
Fundu
+ dim
+dim
s
Reflek
TIO
N
N
FC
not seen

 Fc OS :
Papil N II: round, clear border, cdr0,3
reddish yellow
Vasa: avr 2/3, spasme(-),crossing
phen(-), mikroaneurisma (+)
Retina: hard exudate(+), bleeding(-)
Macula : RF(+), hard exudate (+)
Hasil USG B-scan (OD) potongan axial :
Lensa :echo spike (+)
point like lession(-)
membran like lession (-)
Kesan : most likely vitreus haemorage

Dx :

OD VH+PDR, OS NPDR
moderate +CSME

Treatment:
sit down position
SA 1% ED 1 gtt/24 hour OD
P.pred ED 1gtt/6 hour OD
. Control 1 weeks again

Thank
You