Duty Report

Monday, July 23, 2018

Ophthalmologist: dr. Wisnu Sadasih, Sp.M
Senior Residen: dr. Risa
Junior Residen: dr. Rhema
 Identity
• Name: MR
• Age: 12 y.o
• MR: C704167
• Chief Complaint: pain in the left eye
• Recent history:
Patients come with pain complaints on the left
eye since 2 hours before admission. Complaints
are felt after the left eye is exposed to the cap.
eye pain complaints accompanied by dizziness
(+), nausea (+), excessive excess tears (+),
bleeding in the eyes (-). The patient went to
KMN and was referred to Kariadi Hospital.
• History of trauma(+)
• History using spectacles (-)
• Previous blurred vision history (-)
 OD OS
Visual acuity > 3/60 > 3/60
IOP 17.3 mmHg 15.9 mmHg
Eyelid Edem (-), Spasm (-) Edem (-), spasm (-), hyperemic
(+)
Conjunctiva Injection (-), chemosis (-) Mix injection (+), chemosis (-),
SKB (-), laceration (-), bleeding (-)
Cornea Edem (-) Edem (+) minimal
COA Depth Hifema (+) ± 2 mm
Iris Crypte (+) Crypte (+)
Pupil Round, central, regular, Ø 3 Round, central, regular, Ø 3 mm,
mm, RP (+) N, RAPD (-) RP (+) N, RAPD (-)
Lens Clear Clear
RF (+) bright not brilliant
OTS 5
OS. Hifema Traumatica e.c. Blunt Trauma

Therapy :
• Hospitalization
• Timol 0.25% ed / 12 hours OS
• SA 0.5% ed / 24 hours OS
• P-pred ed / 6 hours OS
• LFX ed / 6 jam OS
• Cloramphenicol e.oint / 8 hours OS
• Tranexamic acid 250 mg / 8 hours PO
• Sleeping position half-sitting
 Identity
• Name: Mr. MR
• Age: 20 y.o
• MR: 704169
• Chief Complaint: right eye feels blocked
• Recent history:
Patients came with a right eye complaint was
blocked since last night (at 12:00 pm). The
patient's perceived complaints are not reduced
and accompanied by blurred vision (+), red eyes
(+), excessive excess tears (-), pain (-). the
patient soaked the right eye into the water.
Since 7 hours ago, the eyes were getting
uncomfortable and the patient dripped the drug
"Insto" 4 times and checked into Kariadi
Hospital.
• History of trauma (+)
• History using spectacles (-)
• Previous blurred vision history (-)
 OD OS
Visual acuity > 3/60 > 3/60
IOP T dig N T dig N
Eyelid Edem (-), Spasm (-) Edem (-), spasm (-)
Conjunctiva Injection (+) siliar, chemosis (-) Injection (+) silier, chemosis (-),
SKB (-)
Cornea Edem (-), flourescein test (+) in Edem (-)
central cornea, size 1x2 mm,
infiltrates (-)
COA Depth Depth
Iris Crypte (+) Crypte (+)
Pupil Round, central, regular, Ø 3 mm, Round, central, reguler,
RP (+) N, RAPD (-) diameter 3 mm, RP (+), RAPD (-)

Lens Clear clear

RF (+) bright (+) bright
 OS. Corneal Erosion e.c. Corpal

Therapy:
• Right eye press 1 x 24 hours
• Oxytetracycline e.oint / 8 hours OD
• Vitamin C 500 mg / 24 hours PO
• Eye polyclinic control 3 days later
Thank You