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Name of examine NIM

: Lisbeth Juni Verawati Marpaung : 05-100

Date of examination : November, 27th 2012 Tutor : Dr. Gilbert W.S Simanjuntak,SpM(K)

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PATIENT IDENTITY Name Age Address Occupation : Mr. H : 55 Years old : Gang Sawo, Dewi sartika :-

II.

ANAMNESIS (November,23rd 2012) Main complains : Sudden pain, redness, blurred vision on the right eye.

Additional complains: Headache, nausea, and swelling on the right eye.

History of Disease Patient came to the Hospital with main complains sudden pain, redness, and blurred vision on her right eye. The pain felt deep in the eye ball and spread to forehead. Besides that, it’s also followed by headache, nausea, and swelling too. These complain had been happening for 3 days. Patient taken an eye drop (Rohto) and Paramex to reduce those symptoms but it didn’t getting better and then he decided to go to the hospital to receive better treatment. This similar complains had not found on the rest of his family member. double vision and itchy eyes denied.

Acute Glaucoma

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III. GENERAL STATUS General condition : Appearance of severe illness Complains-related symptoms : Unremarkable IV. pinguecula (-). Systematic Examination Right Eye Visual Acuity Correction Palpebra Superior/Inferior Tarsal Conjunctiva Bulbar Conjunctiva Hyperemic Ciliary’s injection. pterigium (-) 1/60 Can’t be corrected Edematous Left Eye 6/6 6/6 Quiet Acute Glaucoma Page 2 . General Examination Right Eye Around Eye Appearance General Condition of The Eye Ball Position of The Eye Ball Ocular Mobility Symmetric Normal Symmetric Normal Quiet Severe illness Left Eye Quiet Normal B. history of diabetic denied. history of hypertension denied.Previous disease The patient said that there is no history of trauma on his right eye and he never had the same symptoms like this before. OPHTALMIC STATUS A. injection (-). history of using long-term drug denied. pterigium (-) Quiet Quiet. pinguecula (). injection (-).

central. it’s also followed by headache. These complain had been happening for 3 days. Mr.Cornea Edematous. Acute Glaucoma Page 3 . arcus senilis (-) Normal in depth. bleeding (-) Radier Round. Patient taken an eye drop (Rohto) and Paramex to reduce those symptoms but it didn’t getting better and then he decided to go to the hospital to receive better treatment. and swelling too. light reactive (+) Anterior Chamber Narrow in depth. and blurred vision on her right eye. 55 years old came to the Hospital with main complains sudden pain. RESUME Patient. central. symptoms double vision and itchy eyes denied. arcus senilis (-) Clear. Besides that. redness. The pain felt deep in the eye ball and spread to forehead. nausea. infiltrate (-). H. infiltrate (). ulcer (-). dilated. light reactive (-) Lens clear Clear V. ulcer (-). This similar complains had not found on the rest of his family member. bleeding (-) Iris Pupil Radier Round.

DIFFERENTIAL DIAGNOSE Right Eye Anterior uveitis Keratitis Left Eye - Acute Glaucoma Page 4 .From General Examination on The Right Eye Founded: General condition of eye ball: Appearance of severe illness From Systematic Examination on The Right Eye Founded: Visual acuity Palpebra superior/inferior Tarsal conjunctiva Bulbar conjunctiva Cornea Anterior chamber Pupil : 1/60. light reactive (-) VI. can’t be corrected : Edematous : Hyperemic : Ciliary’s injection : Edematous : Narrow in depth : Dilated. CLINICAL DIAGNOSE Right Eye Acute Glaucoma Left Eye Normal VII.

VIII.5 %.Slit lamp .Campimetric .Gonioscopy .V. 2 times daily If necessary: Oral glycerin 50 % I. MEDICAL TREATMENT For The Right Eye Acetazolamite 500 mg I.Tonometry Acute Glaucoma Page 5 . mannitol 20 % Vitamin K 300 mg tablet. SUGGESTED EXAMINATION . 1 tablet orally 3 times daily If the intraocular pressure remains increased and the progressive loss.V. then 250 mg tablet. surgery might be advised (Iridectomy) visual field show For The Left Eye Pilocarpine 2 %. 2 times daily Pilocarpine 2 %. 3 times daily Preventive peripheral Iridectomy Screening examination: every 2 years or less. 1 tablet orally 4 times daily Timolol 0. IX.

COMPLICATION Right Eye Absolute Glaucoma Left Eye Acute Glaucoma Acute Glaucoma Page 6 .X. PROGNOSIS Right Eye Ad vitam Ad sanationum Ad functionum Bonam Dubia ad bonam Dubia ad bonam Left Eye Bonam Bonam Bonam XI.