RESIDENTS IN CHARGE

KIM / TIG / TAN / FAS

Child. M.Z / 7 y.o.
Admitted on January 5th, 2019
 Chief complaint : Bloody on his left eye
 Patient has been complaining about bloody on his left
eye since 6 hours before admission, redness (+), teary
(+), discharge (-), blurred vision (+), pain (+),
 History of trauma (+) patient playing with his friends
and his left eye has been hit by whip
 patient went to midwife, referred to RSUD Lawang and
referred to RSSA
 History of treatment (-) History of wearing spectacles (-
), history of previous eye disease (-), history of surgery (-
)
 History of his mother’s maternity : always control
to midwife (1x/month)
 Birth history : born SC, crying spontaneously (+),
cyanosis (-), dyspneu (-)
 History of his vaccine : complete in his age
 History of his growth : normal in his age
January 6th, 2019

GENERAL CONDITION
Heart Rate 90x/min
Respiratory Rate 22x/min
Body Temperature 36.7 C
 SUMMARY OF DATABASE
January 5th, 2019

RIGHT EYE LEFT EYE

20/20 Visual Acuity 1/300

spasm (-), edema (-) Eyelid spasm (+), edema (-)

CI (-), PCI (-) Conjungtiva CI (+), PCI (+)
clear Cornea rupture cornea full
thickness@central, prolapse iris
(+)
deep Anterior Chamber Dte, hyphema full dispersed
radline Iris dte
PR (+), round, Ø 3mm Pupil dte
clear Lens dte
n/p IOP Seem n-1/p
Assessment :
LE Trauma Oculi Penetrans with
- Corneal Rupture
- Prolaps iris
- Hyphema full dispersed

Planning:
 Education and Information about the disease and
therapy
 Pro LE Eksploration + Hecting Cornea / GA
 Inj. Tetagam 0,5 ml im
 Laboratory test
 Ro Thorax PA
 Consult to Anasthesiology Department
 Consult to Paediatric Department
Laboratory Result
January 6th, 2019

 HGB : 12,9 g/dl

 RBC : 5,00 106/uL
 WBC : 15,53 103/uL
 Hmt : 39,20 %
 PLT : 428 103/uL
 OT : 20 U/L
 PT : 21 U/L
 GDS : 99 mg/dl
 Ureum : 21,20 mg/dl
 Creatinin : 0,42 mg/dl
 PPT : 10,70 s
 APTT : 29,30 s
 Na / K / Cl : 143 / 4,44 / 108 mmol/L
Radiology Result
January 6th, 2019

Thorax PA
Cor and pulmo within
normal limit
Consult to Anasthesiology
Department
 Assessment
ASA E, Pediatri (7 y.o)

 Planning
Agree to assist GA with intubation

Consult to Paediatric Department

- Diagnose = within normal limit
- Conclusion = there is no contraindication
LE Eksploration + Hecting Cornea / GA
Performed: January 6th, 2019
Diff: -
Comp: -

 Post Surgery Treatment

- Inj. Cefotaxim 2x750 mg iv
- Ibubrofen syr 3x11/2 cth po
- Metilprednisolon tab 3x4 mg po
- Vigamox ed 6x1 gtt OS
- Lyteers ed 6x1 gtt OS
- SA 1% ed 3x1 gtt OS
- Consult to PO division
 RIGHT EYE Day 1-
January 7-th - 2019
Visual Acuity 20/20

Eyelid spasm (-), edema (-)

Conjungtiva CI (-), PCI (-)
Cornea clear
Anterior Chamber deep
Iris radline
Pupil PR (+), round, Ø 3mm
Lens clear
IOP n/p
 Left eye Day 1, january 7th Day 2, january 8th
Visual acuity 1/300 1/300
eyelid Spasm (+) Edema (+) Spasm (+) Edema (+)

conjuntiva CI (+), PCI(+), SCH (+) CI (+), PCI(+), SCH (+)

cornea Suture 7 tigth good Suture 7 tigth good

apposition, siedl (-), Hazy (+) apposition, siedl (-),
Hazy (+)
Anterior chamber Coagulum (+), seem shallow Coagulum (+), seem
shallow
iris dte dte
pupil dte dte
lensa dte dte
IOP N/P N/P
 Day 1
jan 7th, 2019
Assessment LE Trauma Oculi Penetrans Post
Eksploration + Hecting Cornea day 1
with complication
- Rupture cornea
- Prolaps iris
- Hyphema full dispersed
Planning - Cefotaxim inj 2x750 mg
- Ibubrofen syr 3x11/2 cth po
- Metilprednisolon tab 3x4 mg po
- Tranexamic acid tab 3x250 mg po
- Vigamox ed 6x1 gtt OS
- lyteers ed 6x1 gtt OS
- SA 1% ed 3x1 gtt OS
Day 2
jan 8th, 2019
LE Trauma Oculi Penetrans Post
Eksploration + Hecting Cornea day 1
with complication
- Rupture cornea
- Prolaps iris
- Hyphema full dispersed
- Cefotaxim inj 2x750 mg
- Ibubrofen syr 3x11/2 cth po
- Metilprednisolon tab 3x4 mg po
- Tranexamic acid tab 3x250 mg po
- Vigamox ed 6x1 gtt OS
- lyteers ed 6x1 gtt OS
- SA 1% ed 3x1 gtt OS
BEFORE

AFTER