OPHTALMIC RECORD

Examiner NIM Date of exam Tutor

: Hunter Willy Albert Tambunan : 0761050174 : 31 March 2011 : dr. Gilbert. W. S. Simanjuntak, SpM

I.

PATIENT IDENTITY Name Age Sex Religion Address Occupation : Ms. M : 25 years : Female : Moslem : Kulonprogo , Jogjakarta : College student

II.

ANAMNESIS Main complaint Additonal complaint : Red eye on both eyes :

A foreign body sensation, a scratching or burning sensation, itching and purulen exudate with sticky lids on waking and then swelling of the eyelids. Chronology of disease :

A 25 years old female came to dr. YAP Eyes hospital with the main complaint of red eyes on both eyes since 3 days ago. Other than that patient also

complained of a foreign body sensation, a scratching or burning sensation, itching and purulen exudate with sticky lids on waking and then swelling of the eyelids at the same time. Patient admitted that she initially only one eye is red and then transmitted to the other eye. Patient do not treat this complaint with any medication , she also has not been to the doctor to treat the complaint.

Previous disease

Patient never felt the same symptoms before. Patients using contact lenses. Patients denied the presence of a high blood pressure and allergy.

History of family disease

In families of patient has ever suffered like her.

III. GENERAL STATUS General condition Symptom or illness related to the complaint : Mild illness appearance : Not found

IV.

STATUS OFTALMOLOGI A. General examination Parameter Periocular Appearance General Condition of The eye Eyeball position Eyeball movement OD Quiet Quiet Simetric Normal OS Quiet Quiet Simetric Normal

B. Sistematic Examination

Parameter Visual Acuity Supersilia Silia Palpebra Superior/inferior Tarsal conjungtiva Superior/inferior Forniks conjungtiva Superior/inferior Bulbi conjungtiva Cornea Clarity Infiltrate Ulcus Anterior Chamber Iris Pupil

OD 6/6 Quiet Quiet Quiet Hyperemic Hyperemic Hyperemic

Clear No No

OS 6/6 Quiet Quiet Quiet Hyperemic Hyperemic Hyperemic

Clear No No

Deep Radier Chocolate Light reflex (+) Round Isokor Clear

Deep Radier Chocolate Light reflex (+) Round Isokor Clear

Lens

V.

RESUME A 25 years old female came to dr. YAP Eyes hospital with the main complained of red eyes on both eyes since 3 days ago. In addition, patient also complaint of a foreign body sensation, a scratching or burning sensation, itching and purulen exudate with sticky lids in the on waking and then swelling of the eyelids. Patient do not treat this complaint with any medication , she also has not been to the doctor to treat the complaint. General condition : Mild illness appearance From the ophtalmologic examination on both eyes founded Parameter OD OS

Periocular Appearance General Condition of The eye Eyeball position Eyeball movement

Quiet Quiet Simetric Normal

Quiet Quiet Simetric Normal

Parameter Visual Acuity Supersilia Silia Palpebra Superior/inferior Tarsal conjungtiva Superior/inferior Forniks conjungtiva Superior/inferior Bulbi conjungtiva Cornea Clarity Infiltrate Ulcus Anterior Chamber Iris Pupil

OD 6/6 Quiet Quiet Quiet Hyperemic Hyperemic Hyperemic

Clear No No

OS 6/6 Quiet Quiet Quiet Hyperemic Hyperemic Hyperemic

Clear No No

Deep Radier Chocolate Light reflex (+) Round Isokor Clear

Deep Radier Chocolate Light reflex (+) Round Isokor Clear

Lens

VI.

CLINICAL DIAGNOSE Acute Bacterial Conjungtivitis

VII. DIFFERENTIAL DIAGNOSE Acute Viral Conjungtivitis

VIII. MEDICAL TREATMENT - Broad spectrum antibiotics 1 drop / hour for every hours or salv 4-5 x 1 day - Sulfasetamid 10-15% or chloramfenicol salv before sleep

IX.

SUGGEST EXAMINATION Microscopic examination (Conjungtival scrapings stained with Grams stain or Giemsas stain). Resistance test.

X.

PROGNOSE

Ad Vitam Ad Sanasionum Ad Fungsionum

OD Bonam Bonam Bonam

OS Bonam Bonam Bonam

XI.

COMPLICATION Chronic Bacterial Conjungtivitis