MORNING REPORT

Dacryocystitis

RSUD SALEWANGANG MAROS

 Patient’s Identity

Name: Mr. D
Age : 50 years old
Gender : male
Occupation : Enterpreneur
Religion : Islam
Address : Maros
Status : Married
Tribe : Bugis
Medical Record : 251951
Anamnesis : Alloanamnesis
Admitted to the hospital on Tuesday, November 12 th 2019.
 History Taking

Chief Complaint : Pain on the Right Eye

History :

Patient admitted to the hospital with a chief complaint of Pain on the right eye which had been
happening for 2 months before presented to the polyclinic. The patient also complained of
excessive tear and secrete production on the right eye.
There were no complains of itching and decreased vision. History of foreign objects and trauma
were absent. There was no history of taking any drugs or medications. History of previous
diseases : recurrent Conjunctivitis and Dacryocistitis. No family history with the same complaints.
 Visual Acuity Examination

OD Visual 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

Oedema (-) Hyperemia (-), Oedema (-) Hyperemia (-),

Palpebral Margo
Crust (-) Crust (-)
Cilia Squama (-), Madarosis (-) Squama (-), Madarosis (-)
Lacrimal Apparatus Epiphora (+) Epiphora (-)

Conjunctiva Hyperemis (+), Hyperemis (-)

Cornea Membrane (+) Membrane (+)

Anterior Chamber Normal Depth Normal Depth
Iris Brown, Crypt (+) Brown, Crypt (+)
Pupil Round, Central Round, Central
Direct/Indirect Light
Reflex +/+ +/+

RAPD - -
Lens Cloudy Cloudy
Anel Test (-)
Regurgitation Test (+) Secret
 Palpation

OD OS
Ocular pressure Tn Tn
Tumor/Mass (-) (-)
Pre Auricular gland Not palpable Not palpable
DIAGNOSE
OD Dacryocystitis

DIFFERENTIAL DIAGNOSE
Conjunctivitis
Dry Eye
Cellulitis Orbita
 Treatment

 Polidemisin Eye Drop 5 mL 4x1

 Methylprednisolon 4 mg 3x1
 Ciprofloxacin 500 mg 2x1

Education
• Educate the patient that this disease is often recurrent
• Warm compress palpebra
 Prognosis

Quo ad vitam : Bonam

Quo ad functionam : Bonam
Quo ad Cometicam : Bonam
Quo ad sanactionam : Bonam
Thank you!