OPHTALMOLOGY RECORD

CORNEAL ULCER

Anggi Lewis R P Aruan

1161050113

Examiner:

Dr. dr. Gilbert W. S. Simanjuntak, Sp. M (K)

DEPARTMENT OF OPHTALMOLOGY

PERIOD OF 12 JUNE – 22 JULY 2017

FACULTY OF MEDICINE

CHRISTIAN UNIVERSITY OF INDONESIA

JAKARTA

1 1 .discomfor. OPHTALMOLOGY RECORD Name : Anggi Lewis R P Aruan NIM : 1161050113 Date of Examination : Thursday. 2 days after that when he woke up in the morning. sensitive to light. Simanjuntak.. patient felt pain. INTERVIEW ( 8 July 2017) Main complaint : Decreasing of vision in the left eye Additional complaint : redness. white-ish spot in the left eye Course of Disease Patient came to UKI Hospital with chief complaint suddenly decreasing of vision in the left eye since 3 weeks ago. Gilbert W. Sawo. watery. both because the complaints gets better after the medicine and he went to garut for ied. 20 July 2017 Examiner : Dr. RT/RW 01 / 011. Gg. Sp. It felt progressive day by days. and watery. East Jakarta Job : Merchant Religion : Moslem II. Then 2 weeks earlier the patient went to the puskesmas and he got eye drops from there. S. D Age : 45 years old Address : Cawang III. and decreasing in vision. dr. in the left eye. feel discomfort in his left eye. redness in his left eye. according to the patient. and the patient stop using the eye drops. PATIENT IDENTITY Name : Mr. sensitive to light. the patient said he was poked right to the left eye ball.M (K) I. but the patient didn’t know about his eye drops. 3 weeks earlier. his left eye poked by her colleague when he was working as a merchant.

so he came to the puskesmas and referred to UKI Hospital to met an ophtamologist.week ago according to the patient. Patient never using glasses or soft lenses. discomfort. and watery. History of diabetes and hypertension denied. Family Medical History None of his family or relatives had complaints like this before. There are no complaints about his right eye. History of allergics denied. history of eye infection earlier denied. GENERAL STATUS General condition : Moderate illness Awareness : Compos mentis IV. in the left eye come back again. History of Disease . And know he saw white spot in the left eye. General investigator Right Eye Left Eye Around eye appearance Quiet Quiet General Condition of the Normal Hyperemic Eye Ball Position of the Eye Ball Symmetric Symmetric 2 . he felt the complaints like redness. history of both hypertension and diabetes mellitus denied. and got worse than before. Patient had never had any complaint like this before . III. There are no complaints about headache and feeling nauseous. History of having red and itch eyes denied . OPHTALMOLOGIST STATUS A. sensitive to light.

reflex (+) reflex (+) Anterior Chamber Normal deep. crust (-) Tarsal Conjungtiva Hyperemic (-). trichiasis (-) Normal. Not getting better Super Cilia Normal growth. papilar (-). Foggy. trichiasis (-) Palpebra Normal skin colour. madarosis (-) Cilia Normal. tenderness -. Systemic investigator Right Eye Left Eye Visual Acuity 6/6 1/300 Pin Hole . pterigium (-) Pterigium (-) Sclera white white Cornea Round. ulcer (-). cicatrix (-). ulcer (+) sentral . Pinguekula (-). madarosis (-) Normal growth. clear. ectropion (-). bleeding (-) Bulbar Conjungtiva Ciliar injection (-). pinguekula (-). Superior/inferior bleeding (-) follicle (-). entropion (-). Conjungtiva injection (-). hipopion (-). madarosis (-). cicatrix. neovascularization. infiltrate (-). Superior/inferior tenderness (-). ulcer (-). Eye movement Normal to all directions Normal to all directions Donders Confrontation Wide Couldn’t be examined Test B. ectropion (-). edema (-). injection (-). neovascularization (-). crust (-) entropion (-). Normal skin colour. Conjungtiva Ciliar injection (+). hyphema Couldn’t be examined (-) 3 . Hyperemic (-). papilar (-). edema (-). madarosis (-). follicle (-).

It felt progressive day by days. Then 2 weeks earlier the patient went to the puskesmas and he got eye drops from there. patient felt pain. GENERAL EXAMINATION OS : Acies Visus 1 / 300. 1 week ago according to the patient. feel discomfort in his left eye. redness in his left eye. sinekia (-) Couldn’t be examined Pupil Round. in the left eye come back again. his left eye poked by her colleague when he was working as a merchant. the patient said he was poked right to the eye ball. he felt the complains like redness. so he came to the puskesmas and referred to UKI Hospital to met an ophtamologist.discomfor. 4 . and got worse than before. and the patient stop using the eye drops. afakia (-). but the patient didn’t know about his eye drops. Cilliare Injection (+). watery. sensitive to light. Couldn’t be examined subluksasi (-) V. dark brown. according to the patient. 3 mm. sensitive to light. luksasi (-). both because the complaints gets better after the medicine and he went to garut for ied. in the middle. 3 weeks earlier. RESUME Patient came to UKI Hospital with chief complaint suddenly decreasing of vision in the left eye since 3 weeks ago. 2 days after that when he woke up in the morning. and decreasing in vision. foggy kornea and ulcer in sentral. . Iris Radier. indirect light reflex (+) Lens Clear. PH (-). and watery. And know he saw white spot in the left eye. direct Couldn’t be examined light reflex (+).

CLINICAL DIAGNOSE Corneal Ulcer OS ec susp bacterial VII. infiltrate (-). Corneal Ulcer OS ec susp fungal . cicatrix -. Non medication . Do not using eye pad or bandage on the affected eye except when going out - 2. Keratitis bacterialis OS VIII. Medication 5 . ulcer (+) cicatrix (-). Tear. Don’t rub both eyes . neovascularization (-). MEDICAL TREATMENT 1. - Cornea Round. clear. reflex (+) neovascularization -. infiltrate (-). reflex (+) Lens Clear Couldn’t be examined VI. Corneal Ulcer OS ec susp virus . ulcer (-). Wash hand before and after touching the eyes . DIFFERENTIAL DIAGNOSE . sentral.SYSTEMIC EXAMINATION OPHTAMOLOGIST Right Eye Left Eye Visual Acuity 6/6 1/300 Pin Hole .

COMPLICATIONS . Slit lamp with fluorescent test b. . Corneal Perforation . Endoftalmitis XI. PROGNOSIS RIGHT EYE LEFT EYE Ad Vitam Bonam Dubia ad Bonam Ad Sanationum Bonam Dubia ad bonam Ad Fuctionum Bonam Malam 6 . Microbiology culture (cornea scraping) X. Topical Broad spectrum antibiotic  Levofloxacin every 2 hour. 1 drop for OS IX. PLANNED EXAMINATION a.