OPHTHALMOLOGY RECORD

TUTOR: Prof. Dr. dr. JHA Mandang, SpM (K) CREATED BY: Eleazar Christopher L Tobing 0861050035

DEPARTEMENT OF OPHTHALMOLOGY 27 Mei - 22 Juni 2013 MEDICAL FACULTY CHRISTIAN UNIVERSITY OF INDONESIA JAKARTA 2013
OPHTHALMIC RECORD

S : Male : 24 years old : Self-employed : Piyungan Bantul. The same illness did not found in other family members. Jogjakarta : Moslem II. especially when touched and itchy bumps. The history of hypertension.Examinee NIM : Eleazar Christopher L Tobing : 0861050073 Date of exam : June. th 2013 Tutor : Prof. but forgot the name of the medicine. JHA Mandang. Starting from small red bumps then became increasingly large until lower eyelids on both eyes become red and swollen. SpM (K) I. PATIENT IDENTITY Name Sex Age Occupation Adress Religion : Mr. Patients also feel like there is a lump on both the lower eyelid. Patient has never experienced this illness before. Previous disease During the ill patients were taking medication eye ointment to reduce the symptoms. Dr. dr. Diabetic. Bumps accompanied by pain. INTERVIEW Main Complaint Two bumps on the lower eyelids Additional Complaint Pain and itching if touched Chronologist of the illness Patient came to YAP hospital with main complaint is two bumps on the lower of eyelids since 3 weeks before admission. asthma and allergy denied. .

OPHTHALMIC STATUS a. punctate Negative Negative Sensitive Radier. pain (+) Hyperemic (-) Hyperemic (+) Bump (+) Conjunctival Injeksion (+) Hyperemic Normal White Unclear (+). pain (+) Hyperemic (-) Hyperemic (+) Bump (+) Conjunctival Injeksion (+) Hyperemic Normal White Unclear (+). Systematic Examination Right Eye Visual Acuity Correction Supercilia Cilia Superior/Palpebrae Inferior Palpebrae Superior Tarsalis Conjunctiva Inferior Tarsalis Conjunctiva Bulbar Conjunctiva Superior/Inf Fornix Conjunctiva AppratusLacrimalis Sclera Cornea • Infiltrate • Oedema • Ulcus • Sensibility Camera Oculi Anterior • Iris • Pupil Lens • Shadow Test 6/6 Quiet Quiet Normal. brown Isocor Clear Positive Left Eye 6/6 Quiet Quiet Normal. punctate Negative Negative Sensitive Radier. edema (-) Edema (+). brown Isocor Clear Positive .GENERAL STATUS General condition Disease related complaint : Well : Not found III. General Examination Right Eye Around aye appearance General condition of eyes Eye ball positions Eye ball movement Normal Moderate illness Symetric Normal Left Eye Normal Moderate ilness Symetric Normal b. edema (-) Edema (+).

Diabetic. The same illness did not found in other family members. he felt unwell in his eyes like the complaints above. male. Ophthalmic Examination General condition on both of the eyes: moderate illness Right Eye Visual Acuity Correction Supercilia Cilia Sup/InfPalpebrae Sup/InfTarsalis Conjunctiva Bulbar Conjunctiva Sup/Inf Fornix Conjunctiva AppratusLacrimalis Sclera Cornea Infiltrate Oedema Ulcus Sensibility Camera Oculi Anterior Iris Pupil Lens • Shadow Test 6/8 PH 6/7 Quiet Quiet Spasme Hyperemic Normal Hyperemic Normal White Unclear (+).IV. punctate Negative Negative Sensitive Radier. tearing and increased sensitivity to the light on both of the eye since that morning. A day before patient was welding and accidently the electric sparks splashed into his eyes and then when patient woke up that morning. Patient has never experienced this illness before. redness. brown Isocor Direct light reflex (+) Clear Positive • • • • • • . blurry vision. RESUME Patient. The history of hypertension. Previous diseases: Patient did not do a treatment or take medicine to reduce the symptoms. punctate Negative Negative Sensitive Radier. brown Isocor Direct light reflex (+) Indirect light reflex (+) Clear Positive Left Eye 6/8 PH 6/6 Quiet Quiet Spasme Hyperemic Normal Hyperemic Normal White Unclear (+). asthma and allergy denied. 20 years old came to hospital with main complaint is sensation that there is something in the eye with additional complaint pain.

Repeat every 10 minutes • Analgesic o Acular  1 drop/4 times daily • Antibiotic o Eritrhomycin or gentamicin  1 drop/4 times daily • Non medication o Do not rub over the eyes o Use welding mask while working VIII.V.5-1 %)  1 drop/times. SUGGESTED EXAMINATION Bengal Rose test Flurorescein test . DIFFERENTIAL DIAGNOSE • Corneal ulceration • Iritis VII. MEDICAL TRATMENT • Cycloplegic o Cyclopentolate (0. CLINICAL DIAGNOSE ODS trauma caused by radiation VI.

IX. COMPLICATIONS Corneal ulseration Super infection Vision loss . PROGNOSIS Right Eye Ad Vitam Ad Sanationum Ad Functionum Bonam Dubia ad Bonam Bonam Left Eye Bonam Dubia ad Bonam Bonam X.

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