CASE REPORT

Eye Emergency
Room
Patient Identity
Name ID
Sex Male
Date of Birth March, 3rd 1987 (30 years old)
Religion Moslem
Race/Nationality Indonesian
Address Diponegoro Street, Seririt, Buleleng
MRN 17026125
History Taking
Chief Complaint Foreign body

Location On the left eye

Onset Since 4 hours before admitted to hospital

Chronology When he was seeing the builder build, the pieces of iron that
was there flew into his left eye. History of rubbing the eye (+),
history of washing with water (+), history of trying to remove
the foreign body (-)
Quality The patient feel uncomfortable on his left eye

Quantity There is one foreign body seen on his left eye

Modifying This condition doesn’t improve with water washing

Factor
Additional Redness (+), watery (-), dazzled eye (-), blurred vision (-)
Symptoms
History Taking
Past History No history of wearing glasses or having eye problem,
Diabetes Mellitus (-), Hypertension (-)
Family History History of having eye problem in the family was
denied, Diabetes Mellitus (-), Hypertension (-)
Social History Patient works as an entrepreneur
Past No history of past medication
Medication
Allergy Allergic towards food or medication was denied
General Examination
• GCS : E4 V5 M6
• HR : 80 x/minute
• RR : 18 x/minute
• BB : 65 kg
• Temp : 36oC
Ophthalmology Examination
RE LE
6/6 Visual Acuity 6/6
Normal Palpebra Spasm
Calm Conjunctiva CVI PCVI
Foreign body,
Clear Cornea direction at 5
o’clock
Deep Anterior Chamber Deep
Round, Regular, Round, Regular,
Iris
Brown Brown
Pupil reflex (+) Pupil reflex (+)
Pupil
isocore isocore
Ophthalmology Examination
RE LE
Clear Lens Clear
Clear Vitreous Clear
Fundus reflex (+) Funduscopy Fundus reflex (+)
Intra Ocular
N/P N/P
Pressure
Picture of Patient

Picture 1. Patient’s left eye

Assessment and Planning
• Assessment :
LE Foreign Body (gram) in Cornea

• Planning:
•Foreign body extraction with syringe 1cc using LA
•Antibiotic ED 6x1 LE
•Vitamin C tab 2x1
•Artificial tears ED 6x1 LE
•Analgesic tab 3 x 500 mg (if needed)
•Midriasil ED 1 drop in emergency room
•Control on the next day
THANK YOU