DUTY REPORT

November, 5th 2016

Supervisor : dr Afrisal HK, SpM(K)

Senior resident : dr Yurike Tiurma
Junior resident : dr Ivana
 Identity
• Name : Mrs. DH
• Age : 36 yo
• Address : Tandang, Semarang
 History
• Chief complaint :
Her right eye was hit by hand
• Recent history :
One hour before patient came to hospital, while
she had quarrel with her husband, suddently her
right eye was hit by hand from the front. Her eye
felt pain (+), blurred vision (+), redness (+),
bleeding (+), jelly like material (-). She went to
RSDK.
This is the second times she got violence from her
husband, the first is threatened by knife
• Past Medical History :
Trauma (-), using spectacles (-), allergy (-)
blurred vision (+) especially when look far but
she never go to doctor
• Sosioeconomic History :
She is a housewife, her husband is an
employees, she have 2 children.
Payment using BPJS
 Opthtalmological Status
Right Eye Description Left Eye
0.32pH 0.5 Visual acuity 0.16 F2 0.32
17.3 mmHg TIO 17.3 mmHg
Swollen (+), spasm (+), haematom Palpebra Swollen(-), spasm (-)
(+), lower eyelid : laceration (+)
8x2mm, partial thickness, base
muscle, active bleeding (-)
Hyperemis (+), SCB (-), Conjungtiva injectie (-)
laceration (-)

Intact Sclera Intact

Swollen (-), defect (-), fluorescein Cornea Swollen (-)
test (-)
 OD OD OS
Enough depth, VH grade 3, Anterior chamber VH grade 3
hyphema (-)
Crypt (+), iridodialisis (-), Iris Crypt (+)
iridorexis (-)
Round, central, reguler, ø Pupil Round, central, reguler, ø 3mm,
3mm, RP (+) N RP (+) N
clear Lens clear
Bright Fundus Reflex Bright

• Funduscopy both eyes :

bleeding (-), swollen (-), ablation (-)
• OTS : 5
 Laceration
Swollen,
spasm (+)
Diagnose :
• RE partial thickness lower eyelid caused by
blunt trauma
Therapy :
• C-xitrol e oint 4x/day
• Ibuprofen 3x500 mg po
• Cold compress 3x/day 15 minutes
• Visum
• Control 5 days
 Identity
• Name : Mr. ZA
• Age : 38 yo
• Address : Pundan, Kab Semarang
 History
• Chief complaint :
Right eye struck by gerinda
• Recent history :
Eight hours before patient came to hospital, while
he was working suddenly his right was strucked
by gerinda. He felt hyperlacrimation (+), red eye
(+), blurred vision (+), bleeding (-), jelly like
material (-). He went to clinic, given gentamicin &
mefenamic acid, but still bluredprivate
hospitalRSDK.
• Past Medical History :
Trauma (+) strucked by gramalready recovery
Using spectacles (-), blurred vision (-), allergy (-)

• Sosioeconomic History :
He is a mechanic. Expenses by BPJS
 Opthtalmological Status
Right Eye Description Left Eye
0.16 F2 Ph (-) Visual acuity 6/6 E
17.3 mmHg TIO 12.2 mmHg
Swollen (+), spasm (+), excoriation Palpebra Swollen(-), spasm (-)
10x2mm, bleeding (+)
Hyperemis (+), laceration (-), SCB Conjungtiva injectie (-)
(-)
Intact Sclera Intact
Macula (+) Φ 1mm paracentral Cornea Swollen (-)
(+) 5 o’clock, defect (-), gram (-)
Fluoresence (-)
 OD OD OS
CV (+), Cell grade 3, hyphema (-) Anterior VH grade 3
chamber
Crypt (+), iridodialisis (-), Iris Crypt (+)
iridorexis (-)
Oval, central, reguler, ø 4 mm, Pupil Round, central, reguler, ø 3mm,
RP (+) ↓ RP (+) N
Clear, phacodonesis (-) Lens clear
Less Bright Fundus Reflex Bright

• Funduscopy both eyes : obscured, Vh grade 3

Swollen, spasm,
excoriation

Defect (-)
USG B Scan
• Probe : axial vertical
• Gain 80dB
• Lens : echo spike (+),
subluxation (+)
• CV : turbidity (+), point like
lesion (+) spike 20-30%, mass
like lesion (-), membrane like
lesion (-)
 Vitreous opacity, mostly like
vitreous haemorrhage
Diagnose :
• RE vitreous hemorrhage caused by blunt
trauma
• Suspect lens subluxation
Therapy :
• Inpatient pending
• Semivoler
• P pred ED/3 hours RE
• SA 1%/12 hours RE
• Glaucon-KCl 1x250 mg po
• MP 8 mg 2-0-1 po
• Ranitidin/12 hours
• Control Tuesdaydidn’t come3 days
Education :
- Risk IOP, cataract, inflamation
THANK YOU