Case Report

Ophthalmology Ward
 Patient’s Identity
Name IGPAW
Sex Male
Date of birth 31 September 1936
Age 12 years old
Religion Hindu
Race/ Nationality Indonesian
MRN 19010378
 History taking
Chief Sticky eye lids for both eyes
Complaint
Location Both eyes
Onset 2 days BATH
Chronology Few days BATH pasien was consulted for normal fever with
caugh and got few medicine ( amoxicillin, prednisone and
zenirex syrup). After consuming the medicine, pasien found
that there are few bump and blisters on his body which get
worst over time and later when consulted again to Sanglah,
patient was diagnosed with SJS due to medication allergy.
 History taking
Quality -

Quantity Continuous

Modifying -
Factor

Additional -
symptoms
 History taking
Past history Susp TEN with overlapping SJS

Family -
history
Past Xytrol cream
medication Cendo lyteers
Social Smoking (-) , alcohol (-)
History

Allergy Susp drug allergy (prednisone/

amoxicillin/paracetamol/prometazin/guafenesin
)
 Ophthalmology examination
RE LE
2/60 Visual acuity 1/300
Oedema, excoriation Palpebral Oedema, excoriation
(+), crust (-) (+), crust (-)
CVI (+). PCVI(+), Conjunctiva CVI (+). PCVI(+),
Pseudomembrane Pseudomembrane
(+), Follicle (+), (+), Follicle (+),
Symblepharon (-), Symblepharon (-),
membrane (-) membrane (-)
FL(+), Erosion (+), Cornea FL(+), Erosion (+),
Infiltrate (-) Infiltrate (-)
 Ophthalmology examination
RE LE

Deep Anterior chamber Deep

Pupil reflex (+) Pupil Pupil reflex (+)

Normal Lens Normal

clear Vitreous clear
Fundus reflex (+) Funduscopy Fundus reflex(-)

N/P Intra Ocular N/P

Pressure
Normal Eye movement Normal
 Assessment and Planning
Differential Diagnosis : -

Assessment : ODS blepharoconjungtivitis + corneal erosion ec susp TEN

Planning :
o Hospitalized
o Eye toilet every day
o C. Lyteers ED 6X1 ODS
o Flumetholone 6X1 ODS
o BCL ODS
THANK YOU