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OPHTALMOLOGY RECORD

CORNEAL ULCER

Anggi Lewis R P Aruan

1161050113

Examiner:

Dr. dr. Gilbert W. S. Simanjuntak, Sp. M (K)

DEPARTMENT OF OPHTALMOLOGY

PERIOD OF 12 JUNE 22 JULY 2017

FACULTY OF MEDICINE

CHRISTIAN UNIVERSITY OF INDONESIA

JAKARTA
OPHTALMOLOGY RECORD

Name : Anggi Lewis R P Aruan


NIM : 1161050113
Date of Examination : Thursday, 20 July 2017
Examiner : Dr. dr. Gilbert W. S. Simanjuntak, Sp.M (K)

I. PATIENT IDENTITY
Name : Mr. D
Age : 45 years old
Address : Cawang III, Gg. Sawo, RT/RW 01 / 011, East Jakarta
Job : Merchant
Religion : Moslem

II. INTERVIEW ( 8 July 2017)


Main complaint : Decreasing of vision in the left eye
Additional complaint : redness, sensitive to light, and watery,discomfor, in the
left eye, white-ish spot in the left eye

Course of Disease
Patient came to UKI Hospital with chief complaint suddenly decreasing of
vision in the left eye since 3 weeks ago. It felt progressive day by days, according to
the patient, 3 weeks earlier, his left eye poked by her colleague when he was working
as a merchant, the patient said he was poked right to the left eye ball, 2 days after that
when he woke up in the morning, patient felt pain, redness in his left eye, sensitive to
light, watery, feel discomfort in his left eye, and decreasing in vision. Then 2 weeks
earlier the patient went to the puskesmas and he got eye drops from there, but the
patient didnt know about his eye drops, and the patient stop using the eye drops, both
because the complaints gets better after the medicine and he went to garut for ied., 1

1
week ago according to the patient, he felt the complaints like redness, sensitive to
light, and watery, discomfort, in the left eye come back again, and got worse than
before. And know he saw white spot in the left eye, so he came to the puskesmas and
referred to UKI Hospital to met an ophtamologist.
Patient never using glasses or soft lenses, history of eye infection earlier
denied, history of both hypertension and diabetes mellitus denied. History of allergics
denied, There are no complaints about headache and feeling nauseous. There are no
complaints about his right eye.

History of Disease
- Patient had never had any complaint like this before
- History of having red and itch eyes denied
- History of diabetes and hypertension denied.

Family Medical History


None of his family or relatives had complaints like this before.

III. GENERAL STATUS


General condition : Moderate illness
Awareness : Compos mentis

IV. OPHTALMOLOGIST STATUS

A. General investigator
Right Eye Left Eye
Around eye appearance Quiet Quiet
General Condition of the Normal Hyperemic
Eye Ball
Position of the Eye Ball Symmetric Symmetric

2
Eye movement Normal to all directions Normal to all directions
Donders Confrontation Wide Couldnt be examined
Test

B. Systemic investigator

Right Eye Left Eye


Visual Acuity 6/6 1/300
Pin Hole - Not getting better
Super Cilia Normal growth, madarosis (-) Normal growth, madarosis (-)
Cilia Normal, madarosis (-), trichiasis (-) Normal, madarosis (-), trichiasis
(-)
Palpebra Normal skin colour, edema (-), Normal skin colour, edema (-),
Superior/inferior tenderness (-), ectropion (-), tenderness -, ectropion (-),
entropion (-), ulcer (-), crust (-) entropion (-), crust (-)
Tarsal Conjungtiva Hyperemic (-), papilar (-), follicle (-), Hyperemic (-), papilar (-),
Superior/inferior bleeding (-) follicle (-), bleeding (-)
Bulbar Conjungtiva Ciliar injection (-), Conjungtiva Ciliar injection (+), Conjungtiva
injection (-), pinguekula (-), injection (-), Pinguekula (-),
pterigium (-) Pterigium (-)
Sclera white white
Cornea Round, clear, infiltrate (-), ulcer (-), Foggy, ulcer (+) sentral ,
cicatrix (-), neovascularization (-), cicatrix, neovascularization,
reflex (+) reflex (+)
Anterior Chamber Normal deep, hipopion (-), hyphema Couldnt be examined
(-)

3
Iris Radier, dark brown, sinekia (-) Couldnt be examined
Pupil Round, in the middle, 3 mm, direct Couldnt be examined
light reflex (+), indirect light reflex
(+)
Lens Clear, afakia (-), luksasi (-), Couldnt be examined
subluksasi (-)

V. RESUME
Patient came to UKI Hospital with chief complaint suddenly decreasing of
vision in the left eye since 3 weeks ago. It felt progressive day by days, according to
the patient, 3 weeks earlier, his left eye poked by her colleague when he was working
as a merchant, the patient said he was poked right to the eye ball, 2 days after that
when he woke up in the morning, patient felt pain, redness in his left eye, sensitive to
light, watery, feel discomfort in his left eye, and decreasing in vision. Then 2 weeks
earlier the patient went to the puskesmas and he got eye drops from there, but the
patient didnt know about his eye drops, and the patient stop using the eye drops, both
because the complaints gets better after the medicine and he went to garut for ied. , 1
week ago according to the patient, he felt the complains like redness, sensitive to
light, and watery,discomfor, in the left eye come back again, and got worse than
before. And know he saw white spot in the left eye, so he came to the puskesmas and
referred to UKI Hospital to met an ophtamologist.

GENERAL EXAMINATION

OS : Acies Visus 1 / 300, PH (-), Cilliare Injection (+), foggy kornea and ulcer in
sentral.

4
SYSTEMIC EXAMINATION OPHTAMOLOGIST

Right Eye Left Eye


Visual Acuity 6/6 1/300
Pin Hole - -
Cornea Round, clear, infiltrate (-), ulcer (-), Tear, infiltrate (-), ulcer (+)
cicatrix (-), neovascularization (-), sentral, cicatrix -,
reflex (+) neovascularization -, reflex (+)

Lens Clear Couldnt be examined

VI. CLINICAL DIAGNOSE


Corneal Ulcer OS ec susp bacterial

VII. DIFFERENTIAL DIAGNOSE


- Corneal Ulcer OS ec susp fungal
- Corneal Ulcer OS ec susp virus
- Keratitis bacterialis OS

VIII. MEDICAL TREATMENT


1. Non medication
- Dont rub both eyes
- Wash hand before and after touching the eyes
- Do not using eye pad or bandage on the affected eye except when going
out
-
2. Medication

5
- Topical Broad spectrum antibiotic
Levofloxacin every 2 hour, 1 drop for OS

IX. PLANNED EXAMINATION


a. Slit lamp with fluorescent test
b. Microbiology culture (cornea scraping)

X. COMPLICATIONS
- Corneal Perforation
- Endoftalmitis

XI. PROGNOSIS

RIGHT EYE LEFT EYE


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