OPTHALMOLOGIC STATUS

DEPARTEMENT OF OPTHALMOLOGIC
DISEASE

Tutor :

Arranged by:

Luh Inten Prameswari

(1261050175)

KEPANITERAAN ILMU PENYAKIT MATA

PERIODE 28 AGUSTUS – 30 SEPTEMBER 2017
FAKULTAS KEDOKTERAN
UNIVERSITAS KRISTEN INDONESIA
JAKARTA
2017
 OPHTALMIC RECORD

Examiner : Luh Inten Prameswari

NIM : 1261050175

Date of exam : 14 September 2017

I. PATIENT IDENTITY
Name : Mrs. N
Age : 64 years
Sex : Female
Religion : Moslem
Address : Kab Gunung Kidul, Kec. Gedang Sari, Desa Haryomulyo Jari
Bungkus RT 03/011
Occupation : Farmer

II. ANAMNESIS
Main complaint : Itchy eyes
Additonal complaint : Feeling watery in the eyes, eyes are red, dirty eyes,
cannot open her eyes in the morning.

Chronology of disease :
A 64 years old female came to dr. YAP Eye’s hospital with the main
complaint of itchy eyes since 1 week ago. She also complaint that both of her eyes are
watery, eyes are red, itchy and dirty. The consistency of dirt on the eyes is watery and
clear, and hard to open in the morning. The patient haven’t go to the doctor to treat her
symptoms, but she already tried to treat her eyes with an eye drop before, but it didn’t
make the symptoms on both eyes better. She also told that she had a fever. Painful eyes,
decreased eyesight, tired eyes are denied. Blurred vision, history of trauma on the eyes
are denied. She never wear glasses before, history of systemic diseases like diabetes
mellitus and hypertension are denied.
 Previous disease :
The patient never feel these symptoms before. History of allergy and
hypertension were denied. History of diabetes mellitus denied. History of using glasses
denied.

History of family disease :

The family of patient has never suffered symptoms like this before.

III. GENERAL STATUS

General condition : Mild illness appearance
Awareness : Composmentis
Symptom or illness related to the complaint : Not found

IV. STATUS OFTALMOLOGI

A. General examination

Parameter OD OS
Periocular Appearance Quiet Quiet
General Condition of The eye Mild illness appearance Mild illness appearance
Eyeball position Simetric Simetric
Eyeball movement Normal Normal
Eyeball intraocular pressure Normal by palpable Normal by palpable
Tonometer : 18 mmHg Tonometer : 17 mmHg
Vision Field Wide Wide

B. Sistematic Examination

Parameter OD OS
Visual Acuity 0,8 0,7
Correction 1,0 on pin hole 1,0 on pin hole
Supersilia Greyish, symmetric, Greyish, symmetric,
madarosis (-) madarosis (-)
Silia Greyish, madarosis (-), Greyish, madarosis (-),
 trichiasis (-) trichiasis (-)
Palpebra Quiet Quiet
Superior/inferior Tumor (-) Tumor (-)
Infection (-) Infection (-)
Ptosis (-) Ptosis (-)
Margo Palpebra Quiet Quiet
Superior/Inferior Ectro/entropion (-) Ectropion (-)

Crust (-) Crust (-)

Squama (-) Squama (-)

Ulcus (-) Ulcus (-)

Tarsal conjungtiva Hyperemic Normal

Superior/inferior Follicle (+) Follicle (+)

Papil (-) Papil (-)

Scar (-) Scar (-)

Tumor (-) Tumor (-)

Forniks conjungtiva Hyperemic Hyperemic

Superior/inferior Follicle (+) Follicle (+)

Papil (-) Papil (-)

Scar (-) Scar (-)

Tumor (-) Tumor (-)

Bulbi conjungtiva Silier/Conjunctiva Silier/Conjunctiva

Injection (+/+) Injection (+/+)

Chemosis (-) Chemosis (-)

Pinguecula (-) Pinguecula (-)

Pterygium (-) Pterygium (-)

Nevus (-) Nevus (-)

Cornea
 Clarity Clear Clear
  Infiltrate (-) (-)
 Ulcus (-) (-)

Sclera Icteric (-) Icteric (-)

Anterior Chamber
Deepness Deep Deep
Hypema (-) (-)
Hypopion (-) (-)

Iris Radier Radier

Brown Brown
Synechiae (-) Synechiae (-)
Pupil Round, 3mm Round, 3mm
Direct light reflex (+) Direct light reflex (+)
Indirect light reflex (+) Indirect light reflex (+)
Lens Clear Clouding
Shadow test (-) Shadow test (+)

V. RESUME
A 64 years old female came to dr. YAP Eye’s hospital with the main complaint of
itchy eyes since 1 week ago. She also complaint that both of her eyes are watery, eyes
are red, itchy and dirty. The consistency of dirt on the eyes is watery and clear, and
hard to open in the morning. The patient haven’t go to the doctor to treat her symptoms,
but she already tried to treat her eyes with an eye drop before, but it didn’t make the
symptoms on both eyes better. She also told that she had a fever. Painful eyes,
decreased eyesight, tired eyes are denied. Blurred vision, history of trauma on the eyes
are denied. She never wear glasses before, history of systemic diseases like diabetes
mellitus and hypertension are denied.

General condition : Mild illness appearance

From the ophtalmologic examination on both eyes founded

 Parameter OD OS
Visual Acuity 0,8 0,7
Correction 1,0 on pinhole 1,0 on pinhole
Tarsal conjungtiva Hyperemic Hyperemic
Superior/inferior Follicle (+) Follicle (+)

Papil (-) Papil (-)

Scar (-) Scar (-)

Tumor (-) Tumor (-)

Forniks conjungtiva Hyperemic Hyperemic

Superior/inferior Follicle (+) Follicle (+)

Papil (-) Papil (-)

Scar (-) Scar (-)

Tumor (-) Tumor (-)

Bulbi conjungtiva Silier/Conjunctiva Silier/Conjunctiva
Injection (+/+) Injection (+/+)

Chemosis (-) Chemosis (-)

Pinguecula (-) Pinguecula (-)

Pterygium (-) Pterygium (-)

Nevus (-) Nevus (-)

VI. CLINICAL DIAGNOSE

ODS Viral Conjunctivitis

VII. DIFFERENTIAL DIAGNOSE

- Iritant conjunctivitis
- Allergic conjunctivitis
VIII. MEDICAL TREATMENT
Corticosteroid + antibiotic (Polydex : 6x/day, 2 drops per use)

IX. FURTHER EXAMINATION

- Slitlamp biomicroscopy
- Virus culture

X. PROGNOSE

OD OS
Ad Vitam Bonam Bonam

Ad Sanasionum Bonam Bonam

Ad Fungsionum Bonam Bonam

XI. COMPLICATION
- Chronic conjunctivitis
- Keratitis
- Keratoconjunctivitis