presentasi case report.ppt

7/23/2019 presentasi case report.ppt

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CASE REPORTAstrid Feliasari

I 11107063


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cases


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Patient Identity

Name : An. Rea

Se! : "ale

A#e : 6 m$nt%

Address: &'ala II RT.00()00* +',' raya

Et%nic : melay'

-$, :

Reli#i$n : Islam

Patient as e!amined $n -'ne 1/ 01


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Anamnesis

Main complaint :T%e le2t eye l$$+s et $r tears may sill

$4er $nt$ t%e c%ee+.


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Anamnesis

History of disease : Patient and %is arents c$me t$ Ot%alm$l$#ist

it% may$r c$mlain. Patient is t%e t%ird c%ild

in %is 2amily. T%is symt$m is ,e#in since %eas ,$rn. Since %e as ,$rn ,$t% $2 t%e eyesare l$$+s et $r tears may sill $4er $nt$ t%ec%ee+.In t%e a#e $2 2$'r m$nt%s t%e ri#%t eye

didnt s%$ t%at symt$ms anym$re ,'t int%e le2t eyes still sill.

5is arents claim t%at t%e tears didnt st$ t$

sill.


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Past clinical history

5is arents said t%at t%ere is n$ clinical%ist$ry


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Family history

5is ,r$t%er 'sed t$ ,e li+e t%is since %eas ,$rn 'ntil t%e a#e $2 2$'r m$nt%.


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General PhysicalAssestment eneral c$nditi$n : #$$d

Aareness : c$m$s mentis

ital si#n : 8l$$d Press're : 9 mm5#

RR : 0 !)min'te

Temerat're : 37 C


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OD OS

normal Eye ,all$siti$n

n$rmal

Eye "$4ement

Movement (+)

pse!doptosis (")

la#oftalmos (") oedem(")

redness (")

mass (") e$tropion (")

enteropion (")

Pale,ra "$4emen ;


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clear Anterior

'ham&er

'lear

ris colo!r : &ron

sine$ia (")'irc!lar p!pil isochore

Iris)'il Iris c$l$'r : ,r$n sine+ia

9ense clear

'annot &e descri&ed itre$'s Cann$t ,e descri,ed

'annot &e descri&ed F'nd's cann$t ,e descri,ed


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*es!me

Patient and %is arents c$me t$ Ot%alm$l$#istit% T%e le2t eye l$$+s et $r tears may sill $4er$nt$ t%e c%ee+. Patient is t%e t%ird c%ild in %is2amily. T%is symt$m is ,e#in since %e as ,$rn.Since %e as ,$rn ,$t% $2 t%e eyes are l$$+s et$r tears may sill $4er $nt$ t%e c%ee+.In t%e a#e$2 2$'r m$nt%s t%e ri#%t eye didnt s%$ t%atsymt$ms anym$re ,'t in t%e le2t eyes still sill.5is arents claim t%at t%e tears didnt st$ t$ sill.In t%e 2amily %ist$ry %is ,r$t%er 'sed t$ ,e li+e

t%is since %e as ,$rn 'ntil t%e a#e $2 2$'r m$nt%. In t%e insecti$nt%e tears l$$+ sill %is c%ee+ 2r$mt%e le2t eye. T%ere is n$ red eye $r e!'date2$ll$in# it.


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Dia#nose

?$r+in# @ia#n$se:

O,str'cti$n nas$lacrimal d'ct


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Plan for eamination

@ye dissaerarance test @@TOC&E@ TEAR @BCT

A ,l$c+ed tear d'ct is a 2airly c$mm$nand 's'ally tem$rary r$,lem t%at$cc'rs in in2ants %en t%e nas$lacrimal

d'ctt%e assa#e t%at lets tears drain2r$m t%e eye int$ t%e nasal ca4ity,ec$mes $,str'cted $r is cl$sed $D.


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8l$c+ed tear d'cts $cc'r in ' t$ 0ercent $2 ne,$rns. T%e c$nditi$ncalled dacry$sten$sis can aDect ='st $ne

eye $r ,$t%. F$r s$me ,a,ies ,l$c+ed tear d'cts

arent immediately e4ident at ,irt% andmay n$t ,e n$ticed 'ntil t%e ,a,y is am$nt% $ld.


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S"PTO"S

?%en an in2ant %as a ,l$c+ed tear d'ctt%e eye l$$+s et $r tears may sill $4er$nt$ t%e c%ee+ e4en %en %e $r s%e is

n$t cryin#.


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CABSES 1

N$rmally tears are r$d'ced ,y t%e lacrimal#land and t%en m$4e acr$ss t%e eyes it% t%e%el $2 t%e eyelids t$ +ee eyes l',ricated andclean.

?%en a ers$n ,lin+s t%e tears are sG'eeedint$ t%e d'cts in t%e inner c$rner $2 t%e eye.

T%ey t%en drain $'t $2 t%e eyes d$n smallt',esnas$lacrimal d'ctsint$ t%e ,ac+ $2 t%en$se. S$metimes t%e d'cts %a4e n$t 2'lly$ened ,y ,irt% s$ tears cann$t r$erly drain

$'t $2 t%e eye.


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CABSES

F$r m$st c%ildren ,$rn it% a ,l$c+edtear d'ct t%ere is $nly a smallmem,rane ,l$c+in# t%e $enin# %ic%

$ens s$ntane$'sly as t%e in2ant#r$s. Bs'ally t%e mem,rane $ens ,y10 t$ 1 m$nt%s $2 a#e


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@IANOSIS

@ye dissaearance test @@T

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