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WEEKLY REPORT
DIA/ EGA/TAN/ TTA/ ASA
MR. H/35 Y.O
ADMISSION: NOVEMBER 9TH, 2018
Chief complain: Blurred on his left eye
Patient complained of blurry vision that slowly worsen since a month
ago. He also felt slightly pain on his left eyes.
Redness (-), diplopia (-), glare (-), headache (+), scalp tenderness (+)
nausea (-), vomiting (-). fever (+) a day before.
History of trauma (-)
History of treatment (-)
History of previous eye diseases (-)
History of wearing spectacles (-)
Prior medical history: hospitalized because of cardiac and
gastrointestinal problems, but he didn’t know the diagnosis.
History of systemic disease : DM(?) never got laboratory check, HT (-)
History of alcoholic (-)
GENERAL CONDITION
BP: 120/70 mmHg
SUMMARY OF DATA BASE
NOVEMBER 9 TH, 2018
Right Eye Left Eye
Subjective: blurry on left eyes
6/6 Visual Aquity 6/12 ph(-)
spasm -, edema - Eyelid spasm -, edema -
CI - , PCI - Conjungtiva CI - , PCI -
clear Cornea clear
deep Anterior Chamber deep
radline Iris radline
round, Ø 3 mm, RP + , Pupil round, Ø 4 mm, RP + ,
RAPD - RAPD +
clear Lens clear
20.6 mmHg IOP 20.6 mmHg
FDT EBM FDT
pain(-) pain(-)
Right Eye Left Eye
12 FPV 12
4/8 MRD 4/8
10 MLD 10
13 LA 13
Right Eye Left Eye
Diplopia
- - - - - -
- - -
- - - - - -
- - -
- - - - - -
- - -
RGD(+), only can read Ishihara RGD(+), only can read
control plate control plate
wnl Amsler Grid wnl
1.65 Contrast Sensitivity 1.65
1.50
RF: +, Media: clear Funduscopy RF: +, Media: clear
ONH: shape dte, blurry ONH: shape dte, blurry
margin @ sup-inf, orange, Hertel margin @ all quadran,
SV >7, elevation 1D hyperemia, elevation 3D,
Vascular: a/v 2/3 ,scle -, hemorhage +, turtuosity +
cross - 16 16 Vascular: a/v 2/3 ,scle -,
Retina: hemorrhage -, cross -
103
exudate - Retina: hemorrhage -,
Macula: FR +, exu - exudate -
Macula: FR +, exu +
Assessment
RLE edema papil ec. Susp. AAION dd. Optic neuritis
dd. papiledema
Treatment :
• Hospitalization
• Education and information about the diasease,
planning therapy, risk and prognosis
• Laboratory examination
• Methyl prednisolone i.v. inj. 4x250 mg in 100cc NS
• Ranitidin 2x50 mg i.v
• Neurobion drip 1x1 amp i.v.
• Kalk 1x1 tab orally
• Consult to Internal Medicine dept. for metilprednisolon
administration
LAB RESULT
Hb : 13,6 g/dL
Eri : 4,58 x 106
Leu : 3,50 x 103
Hct : 39,3 %
PLT : 204.000
FBG/ 2hPPBG : 74 mg/dl / 66 mg/dl
Ureum / Creatinine : 32,5 / 0,82
SGOT/ SGPT: 35/ 41
LED: 38 mm/ jam
CRP: 0,80 mg/dL
Total cholesterol/ HDL/ LDL/ trigliserida: 186/ 144/ 26/134
INTERNAL MEDICINE DEPT.
Ishihara RGD (+), control plate (+) RGD (+) control plate (+) RGD (+) control plate (+)
83 1517 6x Cannot read: 2, 6, 97, 45 83 6x 7321
3536 Can read: 42, 35, 29, 96 5727 9710 424
2910 16x 97x 1519 45x 3515
9626 7421 5x 262
57x 7x 45x 2x 1615 969
5x 7421 5x
3x 2x
Amsler Grid Wnl
Wnl Wnl
Funduscopy RF: +, Media: clear RF: +, Media: clear RF: +, Media: clear
ONH: shape seems round, ONH: shape seems round, ONH: shape seems round,
blurry margin @ nas-sup- blurry margin @ nas-sup- blurry margin @ nas-sup-inf,
inf, cd ratio dte, orange, inf, cd ratio dte, orange, SV cd ratio dte, orange, SV dte,
SV dte, elevation 2D, dte, elevation 2D, elevation 2D, hemorhage -,
hemorhage -, turtuosity - hemorhage -, turtuosity - turtuosity -
Vascular: a/v 2/3 ,scle -, Vascular: a/v 2/3 ,scle -, Vascular: a/v 2/3 ,scle -, cross
cross - cross - -
Retina: hemorrhage -, Retina: hemorrhage -, Retina: hemorrhage -,
exudate - exudate - exudate -
Macula: FR +, exu - Macula: FR +, exu - Macula: FR +, exu -
Visual Aquity 20/30 ph(-) 20/30 ph(-) 20/50
Eyelid spasm -, edema - spasm -, edema - spasm -, edema -
Conjungtiva CI - , PCI - CI - , PCI - CI - , PCI -
Cornea Clear, white kp’s -, Clear, white kp’s -, Clear, white kp’s +,
fine kp’s +, brown kp’s + fine kp’s +, brown kp’s + fine kp’s +, brown kp’s +
Anterior Deep, flare grade II-III Deep, flare grade II-III Deep, flare grade II,
Chamber cell grade II-III cell grade II-III cell grade II
Iris radline radline radline
Pupil round, Ø 3 mm, RP + , round, Ø 3 mm, RP + , round, midmidri
RAPD dte RAPD dte ec.homatro, RP- , RAPD
dte
Lens clear clear clear
IOP 17.3 mmHg 17.3 mmHg n/p
EBM FDT FDT FDT
pain(-) pain(-) pain(-)
Vitreous cell Grade II Grade II Grade II
Left Eye
Diplopia - - - - - -
- - -
- - - - - - - - -
- - - - - - - - -
Ishihara RGD (+), control plate(+) RGD (+), control plate(+) RGD (+), control plate(+)
Funduscopy RF: +, Media: clear RF: +, Media: clear RF: +, Media: clear
ONH: shape dte, blurry ONH: shape dte, blurry @ ONH: shape dte, blurry
@ all margin, cd ratio all margin, cd ratio dte, @ all margin, cd ratio dte,
dte, hyperemia, SV dte, hyperemia, SV dte, hyperemia, SV dte,
elevation 2-3, peripapil elevation 2D, hemorhage elevation 2-3D, peripapil
hemorhage +, turtuosity +, turtuosity - hemorhage +, turtuosity -
- Vascular: a/v 2/3 ,scle -, Vascular: a/v 2/3 ,scle -,
Vascular: a/v 1/3 ,scle -, cross - cross -, sheating +
cross -, sheating + Retina: hemorrhage -, Retina: hemorrhage +,
Retina: hemorrhage +, exudate - exudate +, flameshape +
exudate +, flameshape + Macula: FR +, exu - Macula: FR -, exu +
Macula: FR -, exu +
Assesment RLE Edem papil ec RE Edem papil ec susp. RE Edem papil ec
susp. AAION dd optic AAION dd optic neuritis susp. AAION dd optic
neuritis with with improvement neuritis with
improvement LE edem papil improvement
susp.AAION dd optic LE edem papil
neuritis + panuveitis ec susp.AAION dd optic
susp. CMV neuritis dd panuveitis
ec susp. CMV
Planning • Methyl prednisolone • Methyl prednisolone •Valgancyclovir tab 2x
i.v. inj. 4x250 mg in i.v. postponed 900 mg PO
100cc NS (II,III,IV,V) • Laboratory •Homatro ed 3x1 LE
• Ranitidin 2x50 mg i.v examination: CD4, IgM •Vosama ed 3x1 LE
• Neurobion drip 1x1 and IgG anti CMV and •Methylprednisolone →
amp i.v. Rubella Stop until 3rd day of
• Kalk 1x1 tab orally • Thorax photo PA valgancycolvir
• Cito consult to Infection consumption
and Immunologi •Cetirizin tab 3x 10 mg
division
• Consult to
Pulmonology and
Internal Medicine dept.
• Pro fundus photo
Monday, Nov 12th
2018
RE USG LE USG
A) LE CMV Retinitis
P)
Valgancyclovir 2x900 mg
Homatropin 2% 3 x 1 drop LE
Vosama ed 3 x 1 drop LE
If there’s strong indication for steroid
administration, adjusted to 0,5mg/kgBW with
sistemic antiviral
PULMONOLOGY DEPT.
A)
Susp. Lung Tuberculosis
Immunocompromised state dt. HIV Infection
P)
Laboratory examination: sputum inducted with NS
3% nebulization
HIV determinant tests
Category 1 Antituberculosis drug if TB (+)
INTERNAL MEDICINE DEPT.
A)
Immunocompromised state dt. HIV infection
Generalized papule + crusta (PPE related to HIV
infection)
P)
IVFD NS 20 drop/min
Cetirizine 1x10 mg orally
Antituberculosis drug from Pulmonology dept.
Antiretroviral wait HIV determinant tests result
FUNDUS PHOTO RE
FUNDUS PHOTO LE
FOLLOW UP DAY 3
NOVEMBER 12 H, 2018
Right Eye Left Eye
Subjective: his vision still same
Visual Aquity 20/50
Eyelid spasm -, edema -
Conjungtiva CI - , PCI -
Cornea Clear, white kp’s +,
fine kp’s +, brown kp’s +
Anterior Chamber Deep, flare grade II,
cell grade II
Iris radline
Pupil round, midmidri ec.homatro,
RP- , RAPD dte
Lens clear
IOP n/p
EBM FDT
pain(-)
- Vitreous cell Grade II
Right Eye Left Eye
- - - Diplopia - - -
- - - - - -
- - -
- - - - - -
- - -
RGD (+) control plate (+) - - - RGD (+) only can read control
83 6x 7321 plate
5727 9710 424 Ishihara
1519 45x 3515
7421 5x 262
2x 1615 969
wnl AG wnl
RF: +, Media: clear Fundus RF: +, Media: clear
ONH: shape round, sharp margin, copy ONH: shape dte, blurry @ all
cd ratio 0,3, orange, SV >7, margin, cd ratio dte, hyperemia,
elevation 1D, turtuosity - SV dte, elevation 2-3D, peripapil
Vascular: a/v 2/3 ,scle -, cross -, hemorhage +, turtuosity -
sheating - Vascular: a/v 2/3 ,scle -, cross -,
Retina: hemorrhage -, exudate -, sheating +
flameshape - Retina: hemorrhage +, exudate +,
Macula: FR +, exu - flameshape +
Macula: FR -, exu +
RE USG LE USG
Treatment :
Metilprednisolon 3 x 8 mg orally postponed until got 3
days of Valgancyclovir
Inj. Ranitidine 2 x 50 mg i.v Ranitidine 2x150 mg orally
Drip Neurobion 1 x 1 amp i.v Neurodex 1 x 1 tab orally
Kalk 1 x 1 tab orally STOP
Homatropin 2% ed 3 x 1 drop LE
Vosama ed 3 x 1 drop LE
Valgancyclovir 2 x 900 mg orally
Controlled to outpatient clinic
BEFORE
AFTER