Ophthalmology Ward

Name NKP
Sex Female
Date of Birth March 5th, 1972 (47 years old)
Religion Hindu
Race/Nationality Indonesian
Job Housewife
Education Junior High School
Address Sema Bitra Gianyar
MRN 18040850
Payment method BPJS
Chief Complain Blurry Vision
Location Right eye
Onset since 8 months ago
Chronology Patient came to Sanglah Hospital complaining blurry vision on the
right eye since 8 months ago. patient said the complaint began in both
eye and getting worsen. blurry vision occurs slowly, persistent, and
disturbing daily activities of patient. other symptoms such as red eye
and pain on the both eye, tunnel vision, headache, nausea and
vomitting were denied

Quality disturbing daily activity

Quantity Chronic progressive

Modifying factor -

Additional -
symptoms
Patient said that he had a head operation in Kupang Hospital
without using the intraocular lens on his left eye.
patient also had the Diabetes Melitus since 1 year and he got the
oral medicine for his diabetes.
other eye problem was denied, allergy was denied.
Family History There’s no one in family member that have the same
complaint. History of allergy (-) and systemic disease (-)
in the family.
Social History .Patient only stays at home and doesn’t go to work

Operative Head operation

History

Medication patient had taken the diabetes medication through the

oral medication 2 times a day

Allergy patient has no allergy to food or drugs

• GCS : E4 V5 M6
• BP : 120/80 mmHg
• HR : 80x/minute
• RR : 16x/minute
• Temp Ax. : 36.5o C
• VAS : 0/10
 RE LE

6/18 Visual Acuity 6/7.5

normal Palpebra Normal

normal Conjunctiva normal

Cornea
Clear clear

VH2 Chamber of Anterior VH2

Regular Iris Regular

 RE LE
Pupillary Reflex (+) Pupil Pupillary Reflex (+)
decreased
Clear Lens Clear

Clear Vitreous Clear

RF (+) Funduscopy RF (+)

CDR 0,8-0,9 CDR 0,3-0,4

23 Intra Ocular Pressure 21

• Assessment :
Oculi Dextra Sinistra Primary Angle Closure Glaucoma

• Planning :
Oculi Dextra pro trabekulektomi + 5FU under LA
THANK YOU