DUTY REPORT

Monday, November 11th 2019

Ophthalmologist : dr. Maharani, Sp.M(K)
Senior Resident : dr. Intan
Junior Resident : dr. Prianka
IDENTITY
• Name : Mr. W
• Age : 41 y.o
• Address : Semarang
• MR : C787359
Chief Complaint : Pain in the left eye

Recent medical history :

• ± 10 days before admission, the patient complained his right eye felt itchy when
he was working. Then the patient went to the midwife for treatment and got an
eyedrop.
• ± 3 days after, the patient complained his right eye were red (+), watery (+),
itchy (+), secrete (+) yellowish, pain (-), blurry vision (-). Then the patient went
to Telogorejo Hospital and he got Ofloxacin and Protagenta eyedrop.
• ± 2 days after, the complaints worsened with blurry vision (+), pain (+), and
there were white patches appeared on the right eye. Then the patient went to
Telogorejo Hospital and he was referred to Kariadi Hospital
• History of diabetes (-), hypertension (-), trauma (-), spectacles usage (-), allergy
(-), asthma (-), past operation (-), heart disease (-), kidney disease (-)
 RE LE
Visual Acuity 1/300 6/6
IOP Tdig N 17.6 mmHg
Palpebra Edema (+), spasm (+) Edema (-), spasm (-)
Conjunctiva Mixed injection (+) Conjunctival injection (-)
Cornea Seidel test (-), defect (+) 8x7mm, infiltrate Clear (+)
(+) 9x8mm, necrotic tissue (+)
Anterior Chamber VH grade II-III VH grade IV
Iris Crypt (+) looming Crypt (+)
Pupil Cannot be evaluated Round, central, regular, Ø 3 mm, pupillary
reflex (+) normal
Lens Cannot be evaluated Clear (+)
Corpus Vitreum Cannot be evaluated Turbidity (-)
Fundus Reflex Cannot be evaluated Bright (+)
Funduscopy Cannot be evaluated Within normal limit
Right Eye
 Left Eye

RE Ultrasonography. We didn’t find point-like lesion, membrane-like

lesion, or mass-like lesion. We use the floating-technique
ultrasonography to acquire this printout
• Working diagnosis :
RE Corneal Ulcer

• Management :
• Gentamicin fortified 0.9% eye drop per hour RE
• Cefazoline fortified eye drop per hour RE
• Sulfas Atropine 1% eye drop per 8-hour RE
• Levofloxacin 1x500mg tab P.O
• Glaukon 1x250mg tab P.O
• KCl 1x250mg tab P.O
• Paracetamol 3x500mg tab P.O
• Advise the patient to control to Merpati Eye Clinic on 12th November 2019
IDENTITY
• Name : Ms. W
• Age : 17 y.o
• Address : Semarang
• MR : C787368
Chief complaint : Pain in left eye

Recent medical history :

• ± 3 hours before admission, the patient complained pain her left eye
after contact with patient’s nails. The pain didn’t go away with rest or
washed with water. Redness (+), watery (+), feels lumpy (+), blurry
vision (-), dazzled vision (-), itchy (-). Because there was no
improvement, the patient then went to Kariadi Hospital.
• History of spectacles usage (+) patient forgets the lens size, diabetes
(-), hypertension (-), trauma (-), allergy (-), asthma (-), past operation
(-), heart disease (-), kidney disease (-)
 W RE LE
Visual Acuity 6/20 6/24
IOP 17.6 mmHg Tdig N
Palpebra Edema (-), spasm (-) Edema (-), spasm (-)
Conjunctiva Conjunctival injection (-) Mixed injection (+)
Cornea Clear (+) Fluorescein test (+), defect (+) 3x4mm
paracentral inferonasal, superficial depth,
infiltrate (-), necrotic tissue (-)
Anterior Chamber VH grade IV VH grade IV
Iris Crypt (+) Crypt (+)
Pupil Round, central, regular, Ø 3 mm, pupillary Round, central, regular, Ø 3 mm, pupillary
reflex (+) normal reflex (+) normal
Lens Clear (+) Clear (+)
Corpus Vitreum Turbidity (-) Clear (+)
Fundus Reflex Bright (+) Bright (+)
Funduscopy Within normal limit Within normal limit
Left Eye
• Working diagnosis :
LE Corneal Erosion
• Management :
• Chloramphenicol eye ointment per 8-hour LE
• Paracetamol 500mg tablet 3x1 if LE felt painful
• Vitamin C tablet 2x1
• Pressure bandage LE for 1 day
• Advise the patient to control to Merpati Eye Clinic on 14th November 2019
THANK YOU