OPTHALMIC RECORD

Tutor:
Dr. Gilbert W.S. Simanjuntak SpM
Examiner:
Fridistha Hamaldhani
0861050074

DEPARTMENT OF OPHTHALMOLOGIC
MEDICAL FACULTY
CHRISTIAN UNIVERSITY OF INDONESIA
JAKARTA 2013

OPHTHALMIC RECORD
Name of Examiner

: Fridistha Hamaldhani

NIM

: 0861050074

Date of examination

: 18th June 2013

Tutor

: dr Gilbert W.S. Simanjuntak SpM

PATIENT IDENTITY
Name

: Mr. S.D

Age

: 20 years old

Address

: Kampung Melayu, East Jakarta

Occupation

: Student

i.

ANAMNESIS (June 14th , 2013)

Main complaint
A lump on the left upper eyelid since 4 days ago
Additional complaint
Painful, tenderness, swelling, and redness.
History of disease
Patient came to hospital with main complaint a lump on the left upper eyelid
since 4 days ago. The problem start as a red small lump on the left upper
eyelid and eventually growing bigger so that the left upper eyelid became very
red and swelling. The swelling was also accompanied by pain especially when
it is touched. The patient didnt give any medications yet. Decreased on vision
was denied. Patient has the tendency to rub his eyes. There was no problem at
the right eye. The patient didnt use an eyeglass before. This similar complaint
had not been found on his family member.

Previous disease
The patient said that he never had this situation before.The presence of
diabetes or high blood pressure denied. History of physical trauma denied,
history of using long-term drug denied, allergies and history of contact lenses
used denied.
II.

GENERAL STATUS
General condition

: Moderate illness

Symptom or illness related to the complaint : None

III.

OPHTHALMIC STATUS
1.

General Examination

Right Eye
Periocular appearance
Quiet
General condition of the eye Normal
Eyeball position
Eyeball movement

Symmetry
Normal

Left Eye
Edema
Moderate
illness
Symmetry
Normal

B. Systematic Examination
Right Eye

Left Eye

Visual acuity

6/6

6/6

Correction

Super cilia

Normal,
Madarosis (-)

Normal,
Madarosis (-)

Cilia

Normal,
Madarosis (-), Trikhiasis (-)

Normal,
Madarosis (-), Trikhiasis (-)

Margo Palpebra superior

Margo Palpebra inferior

Edema (-), tenderness (-), Edema (+), tenderness

ectropion (-), entropion (+),
ectropion
(-),
(-), ulcus (-), krusta (-)
entropion (-), ulcus (-),
krusta (-)
Edema (-), tenderness (-), Edema (-), tenderness (-),
ectropion (-), entropion ectropion (-), entropion
(-), ulcus (-), krusta (-)
(-), ulcus (-), krusta (-)

Tarsal conjunctiva superior

Hyperemic (-), Papilar (-), Hyperemic (+), Papilar (-),

Follicle (-), Bledding (-)
Follicle (-), Bledding (-)

Tarsal conjuntiva inferior

Hyperemic (-), Papilar (-), Hyperemic (-), Papilar (-),

Follicle (-), Bledding (-)
Follicle (-), Bledding (-)

Bulbar conjunctiva

Conjunctiva injection (-), Conjunctiva injection (+),

pinguekula (-), peterigium
(-), secretion (-)
Clear
Infiltrate (-) Ulcus (-)
Arch senile (-)
Normal in depth,
Bledding (-), hyphema(-)

pinguekula (-), peterigium

(-), secretion (-)
Clear
Infiltrat (-) Ulkus (-)
Arch senile (-)
Normal in depth,
Bledding (-),hyphema(-)

Iris

Radier
Colour : Brown

Radier
Colour : Brown

Pupil

Round, isochors
3mm
Light Reflexs : (+)
Clear

Round, isochor
3mm
Light Reflexs : (+)
Clear

Cornea
Anterior chamber

Lens

IV.

RESUME
A 20 years old male came to hospital with main complaint a lump on the left
upper eyelid. The colour of the lump is red accompanied by pain especially
when it is touched. The patient didnt give any medications yet. The patient
has the tendency to rub his eyes. There was no problem on the right eye. .
History of physical trauma denied, history of using long-term drug denied,
allergies and history of contact lenses used denied.

Ophthalmic Examination

Visual acuity
Margo
superior

Right Eye

Left Eye

6/6

6/6

Palpebra Normal

Edema (+), tenderness

(+)

Tarsal
conjunctiva Normal
superior

Hyperemic (+)

Bulbar conjunctiva

Normal

Normal

Cornea

Clear

Clear

Anterior Chamber

Normal in depth

Normal in depth

Iris

Radier

Radier

Pupil

Round, light reactive (+)

Round, light reactive (+)

Lens

Clear

Clear

V.

VI.
VII.

CLINICAL DIAGNOSE
Right Eye

Left Eye

Internal
hordeolum
palpebra superior

Differential Diagnose
Right Eye

Left Eye

Chalazion

MEDICAL
TREATMENT

Warm compresses 3-4 times daily for 10-15 minutes.

Topical antibiotic ointment.
Surgery : incision

VIII. SPECIFIC EXAMINATION

There is no specific examination for this case.
i.

Ad vitam
Ad sanationum
Ad functionum
IX.

PROGNOSIS
Right Eye

Left Eye

Bonam
Bonam
Bonam

Bonam
Dubia ad bonam
Bonam

COMPLICATIONS
Eyelid cellulitis