Rara/Angel/Aryawan/Nindya/Yoga/Cynthia/Ayu
Trisna
Consultant : dr. Wayan Eka Sutyawan, SpM
1 PATIENT
IG Kt Adi Wirawan/Male/25y.o/(09/11/16)
S
Patient
was
refferred
from
Mendoyo Primary health Care
Jembr-ana.
Patient feel pain
in his left eye
after hit by iron
plate since 8
hours ago while
working
breaks
down the iron.
Patient feel
blurry , redness ,
and watery in left
eye.
History
of
wearing
glasses (-)
History
of
Diabetic
(-),
Hypertension (-),
medication (-)
Drug allergy (-)
O
6/6
Normal
Normal
VA
Palpebral
Conjuncti
va
Clear, FL (-)
Cornea
Deep
AC
Round,
regular
Reflex (+),
RAPD(-)
Clear
Iris
Pupil
Lens
Clear
FR(+)
Vitreous
Fundus
13
IOP
A
1/60 PH NI
Spasm
CVI(+), PCVI (+),
SCB (+) at temporal
side
fullthickness
Laceration 8mm and
form like _l , from
paracentral at
5oclock to
peripheral 7oclock.
Iris pigment (+),
Seidel test (+)
Hyphema (+) inferior
at 4-5oclock
Oval, Middilatation
Refleks(-)
Hazy , Iris Pigment
(+)
LE Sharp injury
c/
--SCB
- Fullthickness
Corneal
laceration
--Hyphema
- Iridoplegia
-- Susp
Traumatic
cataract
BETTS Criteria
Type A
Grade D
Zone 1
P
- Hospitalized
- IVFD RL 12 dpm
- Cefoperazone
Sulbactam
2x1 gr IV
- Ketorolac 3x30
mg IV
- Tetagam 1 amp
IM
- Levofloxacin ED
@ hour LE
- LE Pro repair
corneal
laceration with
GA
- Lab examination
- Rontgen Thorax
PA,
Skull AP/Lat
- Consult to
Anesthesia Dept.
Refleks(+) minimal,
Detail difficult to be
examined
Eye
3
Moveme
nt
2
Thorax Foto
Interpretation:
Within normal limit
Skull AP/Lat
5
Laboratory Result
WBC
11.31
RBC
5.00
HB
14.35
PLT
174.70
SGOT
21.1
SGPT
12.60
BUN
9.0
SC
0.83
RBS
85
Na
141
3.4
WITHIN NORMAL
LIMIT
SURGERY REPORT
7
1.
2.
3.
4.
5.
6.
7.
8.
9.
Irigation Aspiration
10.
11.
Gentamycin EO
12.
Wound Dressing
13.
Operation finished
POST SURGERY
8
O
6/6
Normal
Normal
VA
Palpebral
Conjunctiva
1/300
Spasm
CVI(+), PCVI (+)
Clear
deep
Round, regular
Reflex (+),
Clear
Clear
reflex (+)
Cornea
AC
Iris
Pupil
Lens
Vitreous
Fundus
n/p
IOP
Reflex (-)
n/p
Eye
Movement
LE Sharp injury
post repair
corneal
laceration day 1
c/
-Susp Traumatic
cataract
- IVFD RL 12 dpm
- Cefoperazone
sulbactam 2x1
gr IV
- Ketoroloac
3x30mg IV
- Levofloxacin ED
6x1 LE
- P.Pred ed 6x1 LE
- Atropin ed 3x1
LE
- Metilprednisolon
3x 16mg tab
- Consult to
Cornea Lens
division and
take over
10
P.
- Cefoperazone
sulbactam 2x1 gr IV
- Ketoroloac 3x30mg IV
- Levofloxacin ED 6x1 LE
- P.Pred ed 6x1 LE
- Atropin ed 3x1 LE
- Metilprednisolon 3x 16mg tab
O
6/6
Normal
Normal
VA
Palpebral
Conjunctiva
Clear
deep
Round, regular
Reflex (+),
Clear
Clear
reflex (+)
Cornea
AC
Iris
Pupil
Lens
Vitreous
Fundus
n/p
IOP
1/300
Spasm
CVI(+), PCVI (+), SCB at
inferior side
Edema(+), Suture (+)
Deep,Bubble (+)
Oval, Middilation on
atropin
Reflex(-)
Hazy
LE Sharp injury
post
repair
corneal
laceration day 2
c/
-susp traumatic
cataract
- Cefadroxil
tab
2x500mg
- Levofloxacin ED
6x1 drop LE
- P.Pred ed 6x1
drop LE
- Atropin ed 3x1
drop LE
- Metilprednisolon
3x 16mg
- Mefenamic acid
Reflex( -)
n/p
Eye
Movement
3x500mg
Control to
policlinic
on
Monday, 14/11/
2016
13
(14/11/2016)
S
Pain (-)
O
6/6
Normal
Normal
Clear
deep
Round, regular
Reflex (+),
Clear
ONH N II round, well
dermacated, CDR 0,3,
aa/vv 2/3,
retina :
good, macula : reflex
(+)
VA
Palpebral
Conjunctiva
Cornea
AC
Iris
Pupil
Lens
Vitreous
Fundus
IOP
5/60 ph NI
Normal
CVI(+), PCVI (+)
Suture (+),
oedema(+)min
Deep,cell (+), flare (+)
Oval, Middilation on
atropin
Reflex(-)
Hazy
clear
ONH N II round, well
dermacated, aa/vv
2/3,retina :pale,
Macula : reflex (+)
LE Sharp injury
post
repair
corneal
laceration day 2
c/
-susp traumatic
cataract
- Retina
bleeding
and
berlins oedema
- Levofloxacin ED
6x1 drop LE
- P.Pred ed 6x1
drop LE
- Atropin ed 3x1
drop LE
- Metilprednisolon
3x 16mg
Consult to
vitreoretina
division
11,3
13
Eye
Movement
14
VitreoRetina Division
17