MORNING REPORT DEPARTEMENT OF OPHTHALMOLOGY

BADAN KESEHATAN MATA MASYARAKAT

 Patient Identity
Name : Mr. T

Sex : Male

Age : 22 y.o

Address : Dg. Tata

Religion : Islam

Ethnic / Nation : Makassar / Indonesia

Occupation : Mahasiswa

Medical Record Number: 130328

Date of Examination : January 28th, 2019

 History Taking

Main Complaint: discomfort of the right eye

Guided history:
A 22-year-old patient came to BKMM with complaints of discomfo
rt of the right eye. complaints felt since 2 days ago after being expo
sed to sand, pain (+). patients also complain that tears often come o
ut. previous medical history (-)
Ophthalmology Examination
Overview
Visual Acuity Examination

OD Visus OS
20/20 Uncorrected visual acuity 20/20

- Correction -
- Best corrected visual acuity -

- Near visual acuity -

- Correction -
- Best corrected near visual acuity -
Anterior Segment Examination
OD OS
Palpebral Margo Oedema (-) Oedema (-)
Cilia Secret (-) Secret (-)
Lacrimal Apparatus Lacrimation (+) Lacrimation (-)

Conjunctiva Hyperemia (+) Hyperemia (-)

Cornea Clear Clear
Anterior Chamber Normal Depth Normal Depth
Iris Brown, Crypt (+) Brown, Crypt (+)
Pupil Round, Central Round, Central
Direct/Indirect Light +/+ +/+
Reflex
RAPD - -
Lens Clear Clear
Palpation

OD OS
Ocular pressure Tn Tn
Tumor/Mass (-) (-)
Pre Auriculer gland Not palpable Not palpable
 Diagnosis
OD Corpus Alineum Konjungtiva

Differential Diagnosis
Konjungtivitis
 Treatment
- Irrigation
- Alien object extraction
- Bralifet 1 tts/6 jam OD (tobramycin and dexametasone)
- Restavit 1 tab/24 jam

Education
- Tell the patients and families not to rub their eyes.
- Use protective goggles when working and driving.
- if complaints increase as a decrease in vision imme
diately controls again
 Prognosis

Quo ad vitam : Bonam

Quo ad functionam : Bonam
Quo ad Cometicam : Bonam
Quo ad sanactionam : Bonam
THANK YOU