Ophthalmology Ward

Name NS
Sex Male
Date of Birth November 12th, 2006 (10 years old)
Religion Hindu
Race/Nationality Indonesian
Job Student
Education SD
Address Subaya Kintamani Bangli
MRN 16054265
Payment method BPJS
Chief Complaint Swelling and redness in both eyelid

Onset Since 5 days ago

Chronology At first, patient felt itchy and rubbed on his both eyes and the
next day his eyes become small swelling and then become
enlarged. His eyelids also become redness. His complaint since
5 days ago (17/6/2017) and consulted on Monday.

Quality His family told that the swelling and redness appeared slowly
getting worse and decrease of activity
Quantity His family told that the swelling of eyelid is persistent

Modifying Factor His swelling ad redness in both eyelid not improve with warm
Additional compress
Symptoms Redness (+) watery eyes (+) secretion (+)
• Patient never got same complaint before
• A year ago patient have been diagnosed with lymphoma non
hodgkin and he had routinely chemotherapy
• Patient have been diagnosed with Steven Johnson Syndrome a
week ago after got paracetamol.
Family History History of Diabetes Mellitus, Hypertension, Heart
disease, any ophtalmology disease in family was denied
Social History Patient is a student

Operative -
History

Medication Fluorometholon ed 6x1 RE LE

Gentamicin ed 3x1 RE LE
Lyteers ed @ 1 hour 1 drop RE LE
Allergy Food (-), medicine (suspect allergy with paracetamol)
• GCS : E4 V2 M5
• BP : 110/70 mmHg
• HR : 74x/minute
• RR : 16x/minute
• Temp : 37,0o C
• VAS : 0/10
 RE LE
sde Visual Acuity sde
Edema, minimal krusta, Palpebra Edema, minimal krusta,
redness redness
CVI, PCVI Conjunctiva CVI, PCVI minimal

FL (+), erosi Cornea FL(-), clear

Deep Chamber of Anterior Deep

Round, regular Iris Round, regular
 RE LE
Pupil Reflex (+) Pupil Pupil Reflex (+)

Clear Lens Clear

Clear Vitreous Clear

Fundus Reflex (+) Funduscopy Fundus Reflex (+)

N/P Intra Ocular Pressure N/P

• Complete Blood Count :
- WBC : 0,13 x 103/µL
- RBC : 2,23 x 106/µL
- HGB : 6,21 g/dL
- HCT : 18,91 %
- PLT : 7,77x 103/µL
• Biochemistry :
- BUN : 172,9 mg/dL
- SC : 4,36 mg/dL
- Blood Sugar : 130mg/dL
- Albumin : 2,5 g/dL
• Assessment :
- RLE Blefarokonjungtivitis ec SJS
Planning :
• Eye toilet every day
• Fluorometholon ed6x1 ODS
• Lyteers ed @ 1 hour 1 drop ODS
• Gentamicin ed 3x1 ODS
THANK YOU