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CASE REPORT
A. Patient Identity
Name
: Ny. Salamah
Sex
: Female
Age
: 42 years old
Address : Dusun Fajar Karya RT 004/RW 003, Desa Kubu, Kecamatan Kubu
Ethnic
: Melayu
Job
: Farmer
Religion : Islam
Patient was examined on May 15th, 2012.
B. Anamnesis
General condition
: Good
Awareness
: Compos mentis
Vital Signs
Heart Rate
: 80 x/minute
Respiration freq.
: 24 x/minute
Blood Pressure
: 140/80 mmHg
Temperature
: 37,2oC
D. Ophthalmological status
Visual acuity:
OD
OS
:0
: 6/6
Right eye
Ortho
Palpebra
Conjungtiva
Cornea
COA
Left eye
Ortho
Ocular Sinistra
Can move to eight
directions of eye
movement examination
ptosis (-), lagoftalmos (-),
edema(-)
Redness (-), discharge (-) ,
fibrovascular growth (-)
Clear, edema (-), ulcer (-),
infiltrate (-)
clear, deep
Iris colour : brown
Unclear
Lens
Vitreous
Fundus
Clear
Clear
Fundus Reflex (+)Normal
papil with demarcated
edge, C/D ratio 0,4
(aproximately)
OS
OD
-
+
+
+
+
+
+
E. Resume
Patient complained loss of eyesight on ocular dextra after it has penetrated by branch
of mangrove tree on April 24th 2012 at 11.00 am. Patient confessed that there were just
a little blood with a painful on her right eye. She could not see anything and
differentiated between light and dark with her right eye. A few hours after that
accident, patient came to primary health service in her district. Patient confessed that,
in primary health service, her right eye was cleaned with water and gave white
powder, and then, it was covered by bandage. On May 15 th 2012, patient come to
RSUD dr Soedarso, and she complained that she cant see by her right eye anymore.
She felt just a little of pain and itchy on her right eye and did not felt any headache.
And there are some purulent discharge on her right eye
She and her family have not any same of symptoms like she had before.
On examination, in general, she has a good condition in general physical assesment,
but she has a little high of blood pressure.
On eye examination, she has a normal visual acuity and normal condition on her left
eye. On the right eye, she has zero of visual acuity, no eye movement, palpebra
oedema, subconjunctival hemmorage, purulent discharge, corneal oedema, ulcer and
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perforation on right eyes cornea. Camera oculi anterior and vitreus body can not be
assessed.
F. Diagnose
Working Diagnose:
G. Examination
USG of Ocular Dextra
Supposition :
There are semi-compact dissemination
in vitreous body, suspecious : extensive
vitreous inflamation.
Blood Laboratory examination (Complete Blood Test and Chemical Blood Test)
Rontgen Thorax PA
H. Treatment
-
Medicamentous
I. Prognosis
OD
Ad vitam
: malam
Ad functionam
: malam
Ad sanactionam : malam
OS
Ad vitam
: bonam
Ad functionam
: bonam
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Ad sanactionam : bonam
J. Follow Up
J.1 Pre-operation ( May, 22nd 2012)
General condition
: Good
Awareness
: Compos mentis
Vital Signs
Heart Rate
: 76 x/minute
Respiration freq.
: 24 x/minute
Blood Pressure
: 140/90 mmHg
Temperature
: 37 oC
Complain
14,2 g/dl
Ht
42 %
WBC
10,3 K/ul
Platelet
562 K/ul
PGR
88 mg/dl
Bleeding time
2 minutes
Clotting time
7 minutes
Ureum
11 mg/dl
Creatinin
0,8 mg/dl
Radiology examination result :
Theres not any disorder that have been seen in thorax PA radiology.
J.2 Operation ( May, 23rd 2012)
Operator : dr. Muhammad Iqbal, Sp.M, M. Kes.
Assitant operator : Yenni, AMK
Operations start at 14.00 WIB
Patient slept with supine position by general anesthesia
In pre-evisceration, operator found foreign body (branch of plant) with 1
centimeter length and diameter 1 milimeter that still sticked in cornea, trichiasis,
General condition
: Good
Awareness
: Compos mentis
Vital Signs
Heart Rate
: 76 x/minute
Respiration freq.
: 20 x/minute
Blood Pressure
: 120/80 mmHg
Temperature
: 37,0oC
Right eye of patient still bandaged, and have been cleaned in the morning.
Complaint
: nause (+), vomitting (+), headache (+), pain (-), itchy (+)
Actual Treatment
: Good
Awareness
: Compos mentis
Vital Signs
Heart Rate
: 84 x/minute
Respiration freq.
: 20 x/minute
Blood Pressure
: 110/70 mmHg
Temperature
: afebril
Right eye of patient still bandaged, and it openned to examine the ocular dextra.
Finding points in exmn.: hard to open eyelid, blepharospasme, conjungtiva redness (+),
theres protruding of conjungtiva in medial cantus, suture path
horizontally layed in central 1,5 centimeters length.
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Complaint
: nause (-), vomitting (-), headache (-), pain (-), itchy (+), hard
to open the eyelid
Actual Treatment
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