LAPORAN JAGA

Oleh :
Oky Sutarto Putra
I11109022
Patient identity
Name : Tn. M
Sex : Male
Age : 43 y.o
Address : Ketapang
Job : Swasta
Religion : Islam
Anamnesis
Main complaint :
Pain of the right eye
History of disease : Pain of the right eye after
hit by motorcycle tire.
Physical examination
Tanda vital
Conciousness: GCS E4M6V5
HR: 90x/min
RR: 20x/min
Blood pressure: 130/90 mmHg
Temp: 36,4
o

Status Oftalmologis
2
Visus :
OD : 1/300, projection good
OS : 6/6
Eye ball position: ortho
Eye Movement :
OD OS
Status Oftalmologis
3

Status Oftalmologis
OD OS
Movement(+), ptosis (-), edema
(+), lagoftalmos (-)
Palpebra Movement(+), ptosis (-), edema
(-), lagoftalmos (-)
redness (+), discharge (-),
degeneration plaque (-), foreign
body (-), injection (+)
Konjungtiva redness (-), discharge (-),
degeneration plaque (-), foreign
body (-), injection (-)
Edema (+), clear (+), ulcer (-) Kornea Edema (-), clear (+), ulcer (-)
Iris colour : brown, sinekia (-), mid
dilatate,
Circular pupil, anisochore, light
reflex (-)
Iris/pupil Iris colour : brown, sinekia (-),
Circular pupil, anisochore, light
reflex (+)
Afakik Lensa Clear , subluxation (-)

Diagnosis
Diagnosis kerja :
OD : glaukoma sekunder
OS : normal eye

DDx:
Subluxation of the lens
Luxation posterior of the lens
Plans for examination
Visual acuity
Slit lamp
Funduskopi indirect
Perimetri
USG
Tonometri


Treatment
Medikamentosa:
Infus RL 20 tetes/menit
Cefriaxone 2x1 gr iv
Ketorolac 2x1 iv
Ranitidin 2x1
Timol 2x1 gtt od
Floxa 6x1 gtt od
KSR 1x1
Glaucon 3x1
Prognosis
OS :
Ad vitam : bonam
Ad functionam : dubia ad bonam
Ad sanationam : dubia ad bonam