WEEKLY REPORT AIS/YUA/NSA/JAL FEA/EKA/AVE/ADE/IIN

Ch. R / 13 y.o Adm. May 23 th 2016 Chief complain: swelling on his right upper eye lid He felt swelling on his right upper eye lid since 10 days before admission after being scratched by his brother while playing. The wound became more swollen, redness and painful 5 days later, and he got fever for 5 days. History of pain when moving the eyeball (-), nausea (-), vomitting (-), caugh (-), headache (-). - History of medication : history of hospitalized at Bangil General Hospital for 5 days and reffered to RSSA. - History of trauma: (-) - History of surgery: (-) - History of systemic disease : (-)

General Condition GCS: 456

R EL E > 2/60 BP VA > 2/60 BP Sp (+), Ed (+) diffuse size 5,5x4,5 cm, Abcess (+), redness (+), supurative dot (+) Eyelid Sp (-), ed (-) CI (-), PCI (-), chemosis (+) Conj. CI (-), PCI (-) Clear, fl test (-) Cornea clear Deep AC Deep Radline Iris Radline Round, Ø 3mm, RP (+) Pupil Round, Ø 3mm, RP (+) Clear Lens clear Difficult to evaluated IOP N/P

Right EyeLeft Eye Pain (-) Movement of eyeball Pain (-) Diplopia (-) Lymphatic Gland Swelling (-) RGD (-) Ishihara Test RGD (-) FR (+), Detail : wnl Funduscopy FR (+), Detail : wnl

Diagnose RE upper eyelid abscess DD :  Preseptal cellulitis  Orbita cellulitis

7 Head and Orbita CT Scan Pro complete of blood test Intravena ceftriaxone 2 x 750 mg Intravena antrain 3 x 750 mg Infus intravena metronidazole 3 x 225 mg Levofloxacin ed 8 x 1 RE Education for warm compress PLANNING THERAPY

Result of blood test  Hb : 11.3 g/dl  RBC : ³µL  WBC : ³µL  Hematokrit : %  Trombosit : ³µL  Eo/bas/neut/limf/mono :0.2/0.2/66.9/24.6/8.1 %  SGOT/SGPT : 17/38 U/L  GDS : 94 mg/dl  Ur/cr : 28.6/0.54 mg/dl  Na/K/cl : 133/4.15/105 mmol/L

Pro CT-Scan  The abscess was rupture  CT-Scan was canceled

DAY IDAY IIDAY IIIDay IV VA 20/60 20/50 ph 20/40 F 20/6020/50 ph 20/40 Eyelid Sp (-), Ed (+) diffuse size 3x2 cm, Abcess (+), redness (+), supurative dot (-) Sp (-), Ed (+) diffuse,redness (+), supurative dot (-), drain (+) Sp (-), Ed (+) diffuse reduced Abcess (+), redness (+), supurative dot (-) drain (-) Sp (-), Ed (+) diffuse reduced supurative dot (-) Conj. CI (-), PCI (-), chemosis (+) CI (-), PCI (-), chemosis (+) minimal CI (-), PCI (-) Cornea Clear AC Deep Iris Radline Pupil Round, Ø 3mm, RP (+) Lens Clear TIO N/P Movement of eyeball FOLLOW UP RE

ASSESMENTPLANNING THERAPY Day I RE upper eyelid abcess dd : Intravena ceftriaxone 2 x 750 mg Intravena antrain 3 x 750 mg Infus intravena metronidazole 3 x 225 mg Levofloxacin ed 8 x 1 RE Culture and gram examination of abcess discharge Wound toilet Day II RE upper eyelid abcess dd : Intravena ceftriaxone 2 x 750 mg Intravena antrain 3 x 750 mg Infus intravena metronidazole 3 x 225 mg Levofloxacin ed 6 x 1 RE Wound toilet Day III RE upper eyelid abcess dd : Intravena ceftriaxone 2 x 750 mg  phlebitis, patient refused to re-infuse  change to oral Infus intravena metronidazole 3 x 225 mg  change to oral Levofloxacin ed 6 x 1 RE Wound toilet Day IV RE upper eyelid abcess dd : Cefadroxil 2 x 250 mg tab p.o Metronidazole 3 x 250 mg p.o Paracetamole 3 x 250 mg p.o if needeed Wound toilet

Result of gram examination of abcess secret  Growth of aerobic bacteria colonies (-)

DAY I DAY II DAY III FOLLO FFOOLLLLOOW UW UPPFFOOLLLLOOW UW UPPP

FOLLO FFOOLLLLOOW UW UPPFFOOLLLLOOW UW UPPP DAY IV