DUTY REPORT

Saturday Night, October 12th

2019

Ophthalmologist : dr. Wisnu Sadasih, Sp.M

Senior Resident : dr. Dexa
Junior Resident : dr. Prianka
IDENTITY
• Name : Mr. T
• Age : 32 y.o
• Address : Semarang
• MR : C718352
Chief Complaint : Pain in the right eye

Recent medical history :

• ± 12 hours before admission, the patient right eye was struck by a
wind spary from a compressor engine. He said that his right eye was
not hurt, blood (-), jelly-like substance (-), and the patient occasionally
rubbed his eyes. ± 5 hours later, he felt discomfort in his right eye.
Pain (+), redness (+), blurry vision (+), lacrimation (+), jelly-like
substance (-).
• History of diabetes (-), hypertension (-), trauma (-), spectacles usage
(-), allergy (-), asthma (-), past operation (-), heart disease (-), kidney
disease (-)
 RE LE
Visual Acuity 6/15 6/6
IOP Tdig N Tdig N
Palpebra Edema (-), spasm (-), laceration (-) Edema (-), spasm (-), laceration (-)
Conjunctiva Mixed injection (+), laceration (-), secrete (-) Injection (-)
Cornea Minimally edema (+), Seidel test (-), Clear (+)
fluorescein test (+), superficial punctate
defect (+) spread equally at inferior
quadrant, infiltrate (+) around defects,
necrotic tissue (-), laceration (-)
Anterior Chamber VH grade III, blood clot (+) at 1/3 inferior, VH grade IV
hyphema (-)
Iris Crypt (+), iridorhexis (-), iridodialysis (-) Crypt (+)
Pupil Round, central, regular, Ø 3 mm, pupillary Round, central, regular, Ø 3 mm, pupillary
reflex (+) normal reflex (+) normal
Lens Clear (+), subluxation (-), luxation (-) Clear (+)
Right Eye
• Working diagnosis :
RE Keratitis et causa Trauma + Blood Clot

• Management :
• Hospitalized the patient  the patient refused
• Chloramphenicol eye ointment / 8-hour RE
• Levofloxacin ED / 6-hour RE
• Sulfas Atropine 1% ED / 12-hour RE
• Tranexamic acid 500mg tab
• 3x1 tab (1st day)
• 2x1 tab (2nd day)
• 1x1 tab (3rd day)
• Methylprednisolone 16 mg tab  2-0-1
• Ranitidine tab  2x1 tab
• Vitamin C tab  1x1 ta
• Paracetamol 500mg tab  3x1 tab
• Education :
• Total bed rest
• Sleeping position half-sitting (60° head elevation)
• Cold compress RE
• Pressure bandage of RE
• Advise the patient to control to Kariadi Hospital eye clinic at Monday, October
14th 2019
THANK YOU