Duty ReportFriday 22 April 2016

Jaga III : dr. Dina Novita, Sp.MJaga II : dr. GilangJaga I : dr. Monik

identity• Name : Sdr. M• Age : 26 tahun• Work : worker

• Chief Complaint : the right inferior eyelid ripped• Recent History :

±8 hours before go to hospital, patient got traffic accident. The right inferior eyelid was ripped. His right eye suddenly blurred, pain, swell, hemorrhage, no excrete fluids like jelly. It was difficult to open his right eye. Than he went to regional hospital and referred to kariadi hospital.

• No history of using spectacless

OD OS

Visual acuity LP bad LP >3/60Eye movemenet

-3 -3 -3 -2 - 3 -2 -2 -3

free

Eye lid edema (+), fullthickness laceration eyelid sup+inf+ canalis lacrimalis rupture

edema (-) spasm (-)

conjunctiva SKB (+), khemosis (+) Innormal limit

Cornea Edema(+), iris prolaps (-) Jernih (+)

Others Difficult to access In normal imit

Ophthalmology status

OD Canalis Lacrimalis Rupture+susp blowout fracture+rupture bulbi

• Ceftriaxon inj 1gr/12 jam• Ketorolac inj 30 mg/8 jam• Metilprednisolone inj 862,5 mg/12 jam• Ranitidin inj 150 mg/12 hours• Vigamox e.d/jam OD• Pro CT-Scan Orbita

Treatment

CT-Scan result• Intracerebral Haemorrhage with pneumocephal in

frontal lobus dx sin• Right oculi bulbi rupture with intraconal

haemorrhage• Complete fracture in right medial wall maxillari

sinus, right sup rim orbita, right papiracea lamina, right ethmoid, right zygomaticus .

• Right Hematosinus maxillari, ethmoid and frontal• Soft tissue swelling with emphysema subcutis• No increase intracranial pressure.

OD OSVisual acuity NLP >3/60Eye lid Decrease edema (+),

fullthickness laceration eyelid sup+inf+ canalis lacrimalis rupture

edema (-) spasm (-)

conjunctiva SKB (+), khemosis (+) Innormal limitCornea Edema(+), iris prolaps (+) clearOthers Difficult to access In normal limit

Ophthalmology status 3rd day

• Ceftriaxon inj 1gr/12 jam• Ketorolac inj 30 mg/8 jam• Metilprednisolone inj 862,5 mg/12 jam• Ranitidin inj 150 mg/12 hours• Vigamox e.d/jam OD• Enucleasi + recanalisasi + palp. reconstruction

Treatment

terimakasih

Mohon bimbingan dan saran

OTS