1

SUNDAY,26/09 /2010
PT/LN/MG
Consultant : dr Mas Putra SpM
Total Patient = 1
2
1.Markonah,F,74 yo
S O A P
Patient complained
blurred on his left
eye since 2 weeks
ago, redness+,
watery+,discharge+,
pain+.
History of trauma
History of exposed
by small insect -
History of therapy :
By opthalmologist,
but she forgot name
of eye drops.

6/15
Normal

Normal

Clear



Deep

Round, reguler
PR (+)
Clear
Clear
WNL


VA
Palpebra

Conjunctiva

Cornea



AC

Iris/Pupil

Lens
Vitreus
Fundus


1/300
Minimal spasme

CVI (+), PCVI (+)

Odem +,FL +
Ulcus at central
cornea,5x5mm,
1/3 stroma
Deep,Hypopion+

Cant be
evaluated
Cant be
evaluated
Cant be
evaluated

LE Corneal
Ulcer cum
Hypopion








- Hospitalized
-Gram, KOH,cultur
sensitivity
-Lab :
DL,UL,BUN/SC,
SGOT/PT,BSA
-IUFD RL
-Cefotaxim
2x1gram
-LFX ed
first hour:@15min
continue@1hour
-Atropin ed
3x1 OS
-Cenfresh ed
@ jam OS
-Na diclofenac
2x50 mg
-Glaucon
2x250mg
-Aspar k 1x1tab
-Consul ENT,
dental dept,
Internist
-Consul sub div
EED
-Planning USG OS


3
4
5
6
1.Yohanes Selasa,M,52 yo
S O A P
Condition 2/8/2010
Patient complained
blurr vision,redness
Watery+,pain+
Discharge+


2/8/2010:
Gram :
- Leukosit (-)
- Stapylococus (-)
- Diplo gram neg (-)
-Cocus gram pos (+)
KOH :
-Spora (+)
- Hifa (+)

6/15
Normal

Normal

Clear


Deep

Round,regular
PR+
Clear
Clear
WNL
VA
Palpebra

Conjunctiva

Cornea


AC

Iris/Pupil

Lens
Vitreus
Fundus


1/300
Minimal spasme

CVI (+), PCVI (+)

Odem +,
Ulcus at central
cornea,4x5mm,
Deep,Hypopion+

Cant be
evaluated
Cant be
evaluated
Cant be
evaluated

LE Corneal
Ulcer cum
Hypopion
DD/
Endopthalmiti
s







- IUFD RL
-Cefotaxim 2x1gr
-LFX ed @ hour
-Cenfresh ed
@ hour
-Diflucan ed
First hour @15min
Continue @hour
(1 day)
-Diflucan flash
8 drops/min
-C eye lotion
6x1os
-Atropin ed 3x1 os
-Na dic 2x50mg


Condition 3/8/2010
Blurr vision,redness,
Watery, pain
decreased.
6/15
Normal

Normal

Clear


Deep

Round,regular
PR+
Clear
Clear
WNL
VA
Palpebra

Conjunctiva

Cornea


AC

Iris/Pupil

Lens
Vitreus
Fundus

1/300
Minimal spasme

CVI (+), PCVI (+)

Odem +,
Ulcus at central
cornea,4x5mm,
Deep,Hypopion+

Cant be
evaluated
Cant be
evaluated
Cant be
evaluated
LE Corneal
Ulcer cum
Hypopion
DD/
Endopthalmiti
s






-IUFD RL
-Cefotaxim 2x1gr
-LFX ed@ hour
-Cenfresh ed@
hour
-Diflucan ed@
hour
- Atropin ed 3x1os
-C eye lotion ed
6x1 os
-Na dic 2x50mg
-Pro scrapping
cornea