CASE REPORT

Eye Emergency Room

Date: August 27th 2018
 Patient’s Identity
Name NKDD
Sex Female
Date of Birth October 29th 2014 (3 years old)
Religion Hindu
Race/Nationality Indonesian
Address Denpasar

MRN 18035358
 History Taking
Chief Complaint Sting on Right Eye

Location Right Eye

Onset ±5 hours before hospitalized
Patient first time felt stingness on her right
eye 5 hours ago after being splashed by
pamor water
Patient had used water to rinse her eyes.
Patient already given xitrol and irigation in
Chronology
RSUD Klungkung
 History Taking
Quality

Quantity Pain continuously

Didn’t get better after using water to rinse

Modifying Factor
both eyes

Redness (+), uncomfort (+), watery (+),

Additional
blurry vision (+), secret (+)
Symptoms
 History Taking
There is no history of similar incident, no previous
Past History
eye disease, spectacles denied, no systemic disease

Family History of same eye problem in the family was

History denied

Past
Patient didn’t use any medication before
Medication

Allergy Patient has no allergy of drugs or foods

 General Examination
Status Present:

• Compos Mentis (E4V5M6)

• HR : 94 x/minute
• RR : 22 x/minute
• Temp: 36,5 oC
 Ophthalmology Examination
RE LE
FO Visual Acuity FO

edema (+)
Palpebra Normal
spasm (+)
CVI (+), PCVI (+),
secret (+), Conjungtiva Normal
pseudomembran (+)

Fl (+) erosion on 4-7

Cornea Clear
o’clock direction

Deep Anterior Chamber Deep

 Ophthalmology Examination
Normal Iris Normal

Pupil reflex (+), Pupil reflex (+),

Pupil
round, reguler round, reguler
Clear Lens Clear
Clear Vitreous Clear
Fundus reflex (+) Funduscopy Fundus reflex (+)

N/P Intra Ocular Pressure N/P

 Assessment and Planning
Assessment:
RE chemical trauma Ropper Hall 1

Planning :
- Xytrol e.d 4 x 1 gtt RE
- Lyteers e.d 4 x 1 gtt RE
- paracetamol syr 125mg/5ml 3x
- vitamin C syr 3x1sdm
THANK YOU