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MORNING REPORT

RSUD HAJI
KERATITIS
Patient Identity

• Name : Mr.O
• Age : 78 y.o
• No. RM : 235790
• Address : Limbuak, Dsn Rende-Rende
• Nation : Indonesia
• Religion : Islam
• Work : Retired
• Date : July 23th 2019
History Taking

• Main Complaint : Left eye hurts

• Guided History :

A 78-years old male patient, presented to our Clinic with complaints to the left
eye hurts since ± 1 week ago. Complaints accompanied by red eyes, excessive tear
output, photophobia (+), decreased visus (+), foreign body feeling, itching (+),
secretions (+). The patient's history often rubs his eyes so that the eyes become red.
treatment history (-), previous history of complaints (-), history of cataract surgery 6
months ago, history of wearing glasses (-), history of HT disease and DM (-)
Ophthalmology Examination
Visual Acuity Examination

OD Visus OS
20/70 Uncorrected visual acuity 1/60

- Correction -
- Best corrected visual acuity -

- Near visual acuity -


- Correction -
- Best corrected near visual acuity -
Anterior Segment Examination
OD OS
Palpebral Margo Oedema (-) Hyperemia (-), Oedema (-) Hyperemia (-),
Crust (-) Crust (-)
Cilia Squama (-), Madarosis (-) Squama (-), Madarosis (-), secret (+)
Lacrimal Apparatus Lacrimation (-) Lacrimation (+) , secret (+)

Conjunctiva Hyperemis (-), Hyperemis (+),

Cornea clear cloudy (+)


Anterior Chamber Normal Depth Normal Depth
Iris Brown, Crypt (+) Brown, Crypt (+)
Pupil Round, Central Round, Central
Direct/Indirect Light +/+ +/+
Reflex
RAPD - -
Lens clear clear
Palpation

OD OS
Ocular pressure Tn Tn
Tumor/Mass (-) (-)
Pre Auriculer gland Not palpable Not palpable
DIAGNOSE
OS Keratitis

DIFERENTIAL DIAGNOSE

Ulcus Cornea
Uveitis Anterior
Konjungtivitis Bakterial
Treatment
- Plan:
- LFX (Levofloksaxin) 4 dd 1 gtt os
- Cendo Protagenta (Polyvinylpyrrolidone 20 mg) 4 dd 1 gtt os
- Natrium diclofenac 25 mg 2x1
- B com 2x1 tab

Education
- maintain hygiene
- Don't rub your eyes
- use glasses to avoid dust and glare
Prognosis

• Quo ad vitam : Dubia ad Bonam


• Quo ad functionam : Dubia ad Bonam
• Quo ad Cometicam : Dubia ad Bonam
• Quo ad sanactionam : Dubia ad Bonam
Thank you!

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